Provider Demographics
NPI:1114141595
Name:BRADSHAW, MARK F (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:F
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 S OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1404
Mailing Address - Country:US
Mailing Address - Phone:952-442-2518
Mailing Address - Fax:952-442-5040
Practice Address - Street 1:24 S OLIVE ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1404
Practice Address - Country:US
Practice Address - Phone:952-442-2518
Practice Address - Fax:952-442-5040
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10725122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist