Provider Demographics
NPI:1174745046
Name:KENDZIOR, BRADLEY FULTON (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:FULTON
Last Name:KENDZIOR
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 ALLEGHENY BLVD.
Mailing Address - Street 2:P.O. BOX 428
Mailing Address - City:RENO
Mailing Address - State:PA
Mailing Address - Zip Code:16343-0428
Mailing Address - Country:US
Mailing Address - Phone:814-676-5690
Mailing Address - Fax:814-677-4120
Practice Address - Street 1:2119 ALLEGHENY BLVD.
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:PA
Practice Address - Zip Code:16343-0428
Practice Address - Country:US
Practice Address - Phone:814-676-5690
Practice Address - Fax:814-677-4120
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030660L1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics