Provider Demographics
NPI:1225208655
Name:HARPER, BRADFORD WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:WILLIAM
Last Name:HARPER
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 1:1120 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1651
Mailing Address - Country:US
Mailing Address - Phone:208-785-0878
Mailing Address - Fax:
Practice Address - Street 1:1120 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1651
Practice Address - Country:US
Practice Address - Phone:208-785-0878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-32251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0028012Medicaid