Provider Demographics
NPI:1437139623
Name:WOODHAM, BRADLEY M (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:M
Last Name:WOODHAM
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 1:6120 WINKLER RD STE I
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8192
Mailing Address - Country:US
Mailing Address - Phone:239-481-6433
Mailing Address - Fax:239-481-6455
Practice Address - Street 1:6120 WINKLER RD STE I
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8192
Practice Address - Country:US
Practice Address - Phone:239-481-6433
Practice Address - Fax:239-481-6455
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 171011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice