Provider Demographics
NPI:1114093739
Name:BRADFORD, ALFRED GWINN JR (DDS)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:GWINN
Last Name:BRADFORD
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:ALDRED
Other - Middle Name:GWINN
Other - Last Name:BRADFORD
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:3510 MARYMONT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217
Mailing Address - Country:US
Mailing Address - Phone:210-654-6752
Mailing Address - Fax:210-946-0618
Practice Address - Street 1:2522 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207
Practice Address - Country:US
Practice Address - Phone:210-225-4867
Practice Address - Fax:210-225-5643
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX08923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist