Provider Demographics
NPI:1477629061
Name:BULLARD, BRADLEY JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JOHN
Last Name:BULLARD
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 1:120 WALNUT STREET
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987
Mailing Address - Country:US
Mailing Address - Phone:507-454-5854
Mailing Address - Fax:507-454-7533
Practice Address - Street 1:120 WALNUT STREET
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987
Practice Address - Country:US
Practice Address - Phone:507-454-5854
Practice Address - Fax:507-454-7533
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice