Provider Demographics
NPI:1003048752
Name:BRADFORD L PICOT, DDS, P.A.
Entity Type:Organization
Organization Name:BRADFORD L PICOT, DDS, P.A.
Other - Org Name:SOUTHEND DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PICOT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-335-8266
Mailing Address - Street 1:1520 SOUTH BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4786
Mailing Address - Country:US
Mailing Address - Phone:704-335-8266
Mailing Address - Fax:704-335-8267
Practice Address - Street 1:1520 SOUTH BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4786
Practice Address - Country:US
Practice Address - Phone:704-335-8266
Practice Address - Fax:704-335-8267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81581223G0001X, 302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908420Medicaid