Provider Demographics
NPI:1316592330
Name:BRADHAM, SARA ROSE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:ROSE
Last Name:BRADHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 DOCTOR CIR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5050
Mailing Address - Country:US
Mailing Address - Phone:903-757-2495
Mailing Address - Fax:
Practice Address - Street 1:3 DOCTOR CIR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5050
Practice Address - Country:US
Practice Address - Phone:903-757-2495
Practice Address - Fax:903-757-3707
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX355311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice