Provider Demographics
NPI:1568718351
Name:PALLES, JOHN BRADLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRADLEY
Last Name:PALLES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 YEAMANS HALL ROAD
Mailing Address - Street 2:
Mailing Address - City:HANAHAN
Mailing Address - State:SC
Mailing Address - Zip Code:29410
Mailing Address - Country:US
Mailing Address - Phone:843-554-4545
Mailing Address - Fax:843-554-4548
Practice Address - Street 1:1224 YEAMANS HALL ROAD
Practice Address - Street 2:
Practice Address - City:HANAHAN
Practice Address - State:SC
Practice Address - Zip Code:29410
Practice Address - Country:US
Practice Address - Phone:843-554-4545
Practice Address - Fax:843-554-4548
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice