Provider Demographics
NPI:1801443049
Name:LEWISTON DENTAL CARE
Entity type:Organization
Organization Name:LEWISTON DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BULLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-523-1071
Mailing Address - Street 1:560 DEBRA DR
Mailing Address - Street 2:PO BOX 697
Mailing Address - City:LEWISTON
Mailing Address - State:MN
Mailing Address - Zip Code:55952
Mailing Address - Country:US
Mailing Address - Phone:507-523-1071
Mailing Address - Fax:507-523-1078
Practice Address - Street 1:560 DEBRA DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:MN
Practice Address - Zip Code:55952
Practice Address - Country:US
Practice Address - Phone:507-523-1071
Practice Address - Fax:507-523-1078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty