1538333810 NPI number — DR. ROBERT DAVID BRADBERRY DMD

Table of content: DR. ROBERT DAVID BRADBERRY DMD (NPI 1538333810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538333810 NPI number — DR. ROBERT DAVID BRADBERRY DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADBERRY
Provider First Name:
ROBERT
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1538333810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1070 WOODLAWN DR NE
Provider Second Line Business Mailing Address:
STE 250
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30068-4264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-077-8644
Provider Business Mailing Address Fax Number:
770-971-7953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1070 WOODLAWN DR NE
Provider Second Line Business Practice Location Address:
STE 250
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30068-4264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-077-8644
Provider Business Practice Location Address Fax Number:
770-971-7953
Provider Enumeration Date:
04/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  010663 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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