Provider Demographics
NPI:1629183827
Name:ROBERSON, BRADLEY C (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:C
Last Name:ROBERSON
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 1:2440 INGLESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2088
Mailing Address - Country:US
Mailing Address - Phone:478-743-3441
Mailing Address - Fax:478-743-1542
Practice Address - Street 1:2440 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2088
Practice Address - Country:US
Practice Address - Phone:478-743-3441
Practice Address - Fax:478-743-1542
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0121591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice