Provider Demographics
NPI:1174694236
Name:BRADY, JOHN JOSEPH JR (DDS,MSD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:BRADY
Suffix:JR
Gender:M
Credentials:DDS,MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:W HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18202-3810
Mailing Address - Country:US
Mailing Address - Phone:570-455-5011
Mailing Address - Fax:
Practice Address - Street 1:28 E BROAD ST
Practice Address - Street 2:
Practice Address - City:W HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-3810
Practice Address - Country:US
Practice Address - Phone:570-455-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS022227L1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics