Provider Demographics
NPI:1790103570
Name:BRADOW, PAM (RDH)
Entity Type:Individual
Prefix:
First Name:PAM
Middle Name:
Last Name:BRADOW
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MRS
Other - First Name:PAM
Other - Middle Name:
Other - Last Name:OUREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DH
Mailing Address - Street 1:2604 FLINTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4408
Mailing Address - Country:US
Mailing Address - Phone:719-338-2195
Mailing Address - Fax:
Practice Address - Street 1:2604 FLINTRIDGE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4408
Practice Address - Country:US
Practice Address - Phone:719-338-2195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000905927124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist