Provider Demographics
NPI:1104963537
Name:SIEVERT, BRADLEY E (DMD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:E
Last Name:SIEVERT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16016 BOONES FERRY RD
Mailing Address - Street 2:STE.100
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4357
Mailing Address - Country:US
Mailing Address - Phone:503-636-4576
Mailing Address - Fax:503-697-5069
Practice Address - Street 1:16016 BOONES FERRY RD
Practice Address - Street 2:STE.100
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4357
Practice Address - Country:US
Practice Address - Phone:503-636-4576
Practice Address - Fax:503-697-5069
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD77801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice