Provider Demographics
NPI:1326194564
Name:BRADLEY, EMILY J (DMD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:J
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:E
Other - Middle Name:JAYNI
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 1619
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-0032
Mailing Address - Country:US
Mailing Address - Phone:706-769-1994
Mailing Address - Fax:706-769-1997
Practice Address - Street 1:1091 PARK DR
Practice Address - Street 2:STE A
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-2014
Practice Address - Country:US
Practice Address - Phone:706-769-1994
Practice Address - Fax:706-769-1997
Is Sole Proprietor?:No
Enumeration Date:2007-01-27
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0100041223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000300671JMedicaid