Provider Demographics
NPI:1376534800
Name:BRADFORD, ROBERTS JOSEPH SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERTS
Middle Name:JOSEPH
Last Name:BRADFORD
Suffix:SR
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 1:600 TUSCULUM BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-3951
Mailing Address - Country:US
Mailing Address - Phone:423-638-5141
Mailing Address - Fax:423-638-5131
Practice Address - Street 1:600 TUSCULUM BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-3951
Practice Address - Country:US
Practice Address - Phone:423-638-5141
Practice Address - Fax:423-638-5131
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS001655122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3212523Medicaid