Provider Demographics
NPI:1790781623
Name:BRADFORD FAMILY DENTISTRY, PL
Entity Type:Organization
Organization Name:BRADFORD FAMILY DENTISTRY, PL
Other - Org Name:BRADFORD FAMILY DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCHESE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, RPH
Authorized Official - Phone:904-964-7501
Mailing Address - Street 1:315 W CALL ST
Mailing Address - Street 2:
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091-3113
Mailing Address - Country:US
Mailing Address - Phone:904-964-7501
Mailing Address - Fax:904-964-7503
Practice Address - Street 1:315 WEST CALL STREET
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-3113
Practice Address - Country:US
Practice Address - Phone:904-964-7501
Practice Address - Fax:904-964-7503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 074451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty