Provider Demographics
NPI:1437235728
Name:HIGGINBOTHAM, BRADLEY DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DAVID
Last Name:HIGGINBOTHAM
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 1:200 S 29TH ST
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-3449
Mailing Address - Country:US
Mailing Address - Phone:712-323-5801
Mailing Address - Fax:712-388-0553
Practice Address - Street 1:200 S 29TH ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3449
Practice Address - Country:US
Practice Address - Phone:712-323-5801
Practice Address - Fax:712-388-0553
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA67881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0196410Medicaid