1790781623 NPI number — BRADFORD FAMILY DENTISTRY, PL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790781623 NPI number — BRADFORD FAMILY DENTISTRY, PL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADFORD FAMILY DENTISTRY, PL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BRADFORD FAMILY DENTISTRY
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790781623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 W CALL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STARKE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32091-3113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-964-7501
Provider Business Mailing Address Fax Number:
904-964-7503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 WEST CALL STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STARKE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32091-3113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-964-7501
Provider Business Practice Location Address Fax Number:
904-964-7503
Provider Enumeration Date:
06/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MARCHESE
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
904-964-7501

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN 07445 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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