Provider Demographics
NPI:1417516733
Name:DIMINICK, BRADLEY BISHOP (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:BISHOP
Last Name:DIMINICK
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 1:5642 JOHN GAINES BLVD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-6532
Mailing Address - Country:US
Mailing Address - Phone:423-863-6114
Mailing Address - Fax:
Practice Address - Street 1:2975 FORT HENRY DR STE A
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-4005
Practice Address - Country:US
Practice Address - Phone:423-247-9196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN110781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice