Provider Demographics
NPI:1366978082
Name:MOURITSEN, BRADLY JAMES (DMD)
Entity type:Individual
Prefix:DR
First Name:BRADLY
Middle Name:JAMES
Last Name:MOURITSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3467 PINE RIDGE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-3832
Mailing Address - Country:US
Mailing Address - Phone:239-251-5045
Mailing Address - Fax:
Practice Address - Street 1:3467 PINE RIDGE RD STE 101
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-3832
Practice Address - Country:US
Practice Address - Phone:239-251-5045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD1172122300000X
UT10341065-9922122300000X
FLDN25384122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist