Provider Demographics
NPI:1902803638
Name:BRADLEY, GEORGE ROBERT (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ROBERT
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-1830
Mailing Address - Country:US
Mailing Address - Phone:830-249-2495
Mailing Address - Fax:830-249-8228
Practice Address - Street 1:123 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-1830
Practice Address - Country:US
Practice Address - Phone:830-249-2495
Practice Address - Fax:830-249-8228
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX149041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics