Provider Demographics
NPI:1659384105
Name:BRADLEY, CHARLES WESLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WESLEY
Last Name:BRADLEY
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 1:8315 WALNUT HILL LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4218
Mailing Address - Country:US
Mailing Address - Phone:214-378-7930
Mailing Address - Fax:
Practice Address - Street 1:8315 WALNUT HILL LN
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4218
Practice Address - Country:US
Practice Address - Phone:214-378-7930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX130641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice