Provider Demographics
NPI:1538177431
Name:JEREN, BRADLEY K (DDS)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:K
Last Name:JEREN
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 1:17991 MAHONING AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE MILTON
Mailing Address - State:OH
Mailing Address - Zip Code:44429
Mailing Address - Country:US
Mailing Address - Phone:330-654-3253
Mailing Address - Fax:330-654-3252
Practice Address - Street 1:17991 MAHONING AVE
Practice Address - Street 2:
Practice Address - City:LAKE MILTON
Practice Address - State:OH
Practice Address - Zip Code:44429
Practice Address - Country:US
Practice Address - Phone:330-654-3253
Practice Address - Fax:330-654-3252
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH17658122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0591622Medicaid