Provider Demographics
NPI:1407853567
Name:RHODES, BRADFORD JAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:JAY
Last Name:RHODES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 SE 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1112
Mailing Address - Country:US
Mailing Address - Phone:503-255-7095
Mailing Address - Fax:503-255-7096
Practice Address - Street 1:1110 SE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1112
Practice Address - Country:US
Practice Address - Phone:503-255-7095
Practice Address - Fax:503-255-7096
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR69701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice