Provider Demographics
NPI:1114960531
Name:WESTFALL, BRADLEY GENE (DDS)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:GENE
Last Name:WESTFALL
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 1:430 W 6TH ST
Mailing Address - Street 2:P.O. BOX 65
Mailing Address - City:CHELSEA
Mailing Address - State:OK
Mailing Address - Zip Code:74016-1640
Mailing Address - Country:US
Mailing Address - Phone:918-789-2515
Mailing Address - Fax:918-789-2516
Practice Address - Street 1:430 W 6TH ST
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:OK
Practice Address - Zip Code:74016-1640
Practice Address - Country:US
Practice Address - Phone:918-789-2515
Practice Address - Fax:918-789-2516
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK47761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10011320BMedicaid