Provider Demographics
NPI:1508005372
Name:BRADFORD, JOHN PHILIP (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PHILIP
Last Name:BRADFORD
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 1:3821 8TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-295-3128
Mailing Address - Fax:619-295-3279
Practice Address - Street 1:3821 8TH AVENUE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-295-3128
Practice Address - Fax:619-295-3279
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA446571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice