Provider Demographics
NPI:1235142282
Name:BRADSHAW, JOHN W (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
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 1:189 CORPORATE DR STE 30
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2386
Mailing Address - Country:US
Mailing Address - Phone:423-929-1126
Mailing Address - Fax:423-929-8111
Practice Address - Street 1:189 CORPORATE DR STE 30
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2386
Practice Address - Country:US
Practice Address - Phone:423-929-1126
Practice Address - Fax:423-929-8111
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20051223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3209305Medicaid