Provider Demographics
NPI:1902452139
Name:BRADLEY ROBERTS & ASSOCIATES PLLC
Entity type:Organization
Organization Name:BRADLEY ROBERTS & ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-282-9959
Mailing Address - Street 1:7170 W CAMINO SAN XAVIER STE C109
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-0862
Mailing Address - Country:US
Mailing Address - Phone:623-282-9959
Mailing Address - Fax:
Practice Address - Street 1:1135 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2701
Practice Address - Country:US
Practice Address - Phone:623-282-9959
Practice Address - Fax:602-429-8200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty