Provider Demographics
NPI:1467677344
Name:CHARLES W BRADLEY DDS PA
Entity Type:Organization
Organization Name:CHARLES W BRADLEY DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-378-7930
Mailing Address - Street 1:8315 WALNUT HILL LN
Mailing Address - Street 2:200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4218
Mailing Address - Country:US
Mailing Address - Phone:214-378-7930
Mailing Address - Fax:
Practice Address - Street 1:8315 WALNUT HILL LN
Practice Address - Street 2:200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4218
Practice Address - Country:US
Practice Address - Phone:214-378-7930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13064122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty