Provider Demographics
NPI:1427740794
Name:BRADLEY A. ELI DENTAL CORPORATION
Entity type:Organization
Organization Name:BRADLEY A. ELI DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ELI
Authorized Official - Suffix:
Authorized Official - Credentials:DND
Authorized Official - Phone:844-235-9881
Mailing Address - Street 1:5830 OBERLIN DR STE 202
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3754
Mailing Address - Country:US
Mailing Address - Phone:844-235-9881
Mailing Address - Fax:760-436-5123
Practice Address - Street 1:5830 OBERLIN DR STE 202
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3754
Practice Address - Country:US
Practice Address - Phone:844-235-9881
Practice Address - Fax:760-436-5123
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRADLEY A. ELI DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-05-24
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X2210XDental ProvidersDentistOrofacial PainGroup - Multi-Specialty