Provider Demographics
NPI:1174597561
Name:BROWN, BRADLEY JESSE (DDS)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JESSE
Last Name:BROWN
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 1:101 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ELLWOOD CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16117-2303
Mailing Address - Country:US
Mailing Address - Phone:724-752-1506
Mailing Address - Fax:724-752-2108
Practice Address - Street 1:101 5TH ST
Practice Address - Street 2:
Practice Address - City:ELLWOOD CITY
Practice Address - State:PA
Practice Address - Zip Code:16117-2303
Practice Address - Country:US
Practice Address - Phone:724-752-1506
Practice Address - Fax:724-752-2108
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025807L1223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABR509853OtherUNITED CONCORDIA PROVIDER