Provider Demographics
NPI:1164952974
Name:BRADFORD, HOLLY A (DMD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:A
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1669 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-9468
Mailing Address - Country:US
Mailing Address - Phone:317-745-5173
Mailing Address - Fax:317-745-5023
Practice Address - Street 1:1669 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-9468
Practice Address - Country:US
Practice Address - Phone:317-745-5173
Practice Address - Fax:317-745-5023
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012727A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice