Provider Demographics
NPI:1790040616
Name:BRADFORD, KATIE ELIZABETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:ELIZABETH
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KATIE
Other - Middle Name:ELIZABETH
Other - Last Name:WOLZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:139 ROSE GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3164
Mailing Address - Country:US
Mailing Address - Phone:573-275-3143
Mailing Address - Fax:
Practice Address - Street 1:139 ROSE GARDEN LN
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-3164
Practice Address - Country:US
Practice Address - Phone:573-275-3143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN102211223D0004X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
No1223G0001XDental ProvidersDentistGeneral Practice