Provider Demographics
NPI:1568614584
Name:J. DWIGHT BRADSHAW DDS
Entity Type:Organization
Organization Name:J. DWIGHT BRADSHAW DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J.DWIGHT
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-484-1444
Mailing Address - Street 1:5501 BENNETTS PASTURE RD STE D
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1500
Mailing Address - Country:US
Mailing Address - Phone:757-484-1444
Mailing Address - Fax:757-484-3712
Practice Address - Street 1:5501 BENNETTS PASTURE RD STE D
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-1500
Practice Address - Country:US
Practice Address - Phone:757-484-1444
Practice Address - Fax:757-484-3712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty