Provider Demographics
NPI:1750328498
Name:BRADFORD, JOHN DAVID II (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:BRADFORD
Suffix:II
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 1:2010 W CHESTER PIKE
Mailing Address - Street 2:SUITE 128
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-2700
Mailing Address - Country:US
Mailing Address - Phone:610-449-2100
Mailing Address - Fax:610-449-9415
Practice Address - Street 1:2010 W CHESTER PIKE
Practice Address - Street 2:SUITE 128
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2700
Practice Address - Country:US
Practice Address - Phone:610-449-2100
Practice Address - Fax:610-449-9415
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-027005-L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU27055Medicare UPIN
PAQPR685244Medicare ID - Type Unspecified