Provider Demographics
NPI:1558544007
Name:BRADSHAW, CAROL LAVERN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:LAVERN
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19005 WILEYS WELL RD
Mailing Address - Street 2:
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92225-2287
Mailing Address - Country:US
Mailing Address - Phone:760-278-9755
Mailing Address - Fax:
Practice Address - Street 1:19005 WILEYS WELL RD
Practice Address - Street 2:
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-2287
Practice Address - Country:US
Practice Address - Phone:760-278-9755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36892122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist