Provider Demographics
NPI:1194701524
Name:SMITH, BRADLEY JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JOHN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 476
Mailing Address - Street 2:BOX1159
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96322
Mailing Address - Country:JP
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 476
Practice Address - Street 2:BOX1159
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96322
Practice Address - Country:JP
Practice Address - Phone:314-252-3747
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019024984122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist