Provider Demographics
NPI:1356900872
Name:LANCE, BRADLEY (DDS)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:LANCE
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 1:13510 BECKER PLACE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-4198
Mailing Address - Country:US
Mailing Address - Phone:314-605-3402
Mailing Address - Fax:
Practice Address - Street 1:7766 WINGHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3601
Practice Address - Country:US
Practice Address - Phone:636-561-4117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-08
Last Update Date:2019-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019019262122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist