Provider Demographics
NPI:1720181076
Name:TWADDLE, BRAD A (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:A
Last Name:TWADDLE
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 1:3705 HUNTER VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203
Mailing Address - Country:US
Mailing Address - Phone:573-445-7482
Mailing Address - Fax:
Practice Address - Street 1:1906 CORONA RD
Practice Address - Street 2:STE 200
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203
Practice Address - Country:US
Practice Address - Phone:573-234-2774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0157241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO015724OtherLICENSE #
MO1795492-7OtherTAX ID #