Provider Demographics
NPI:1659624245
Name:BOCKHORST, BRADLEY COBB (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:COBB
Last Name:BOCKHORST
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 1:21512 COUNTRYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6559
Mailing Address - Country:US
Mailing Address - Phone:949-583-0935
Mailing Address - Fax:760-732-3404
Practice Address - Street 1:3231 WARING CT
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4510
Practice Address - Country:US
Practice Address - Phone:760-732-3456
Practice Address - Fax:760-732-3404
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist