Provider Demographics
NPI:1558412734
Name:JUSTESEN, BRAD D (DDS)
Entity type:Individual
Prefix:DR
First Name:BRAD
Middle Name:D
Last Name:JUSTESEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2120 W GUADALUPE RD
Mailing Address - Street 2:#5
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-7366
Mailing Address - Country:US
Mailing Address - Phone:480-839-0985
Mailing Address - Fax:480-730-8631
Practice Address - Street 1:2120 W GUADALUPE RD
Practice Address - Street 2:#5
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-7366
Practice Address - Country:US
Practice Address - Phone:480-839-0985
Practice Address - Fax:480-730-8631
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
86-0471157OtherTAX ID