Provider Demographics
NPI:1790952489
Name:BRADFORD C SHINAMAN DDS PA
Entity Type:Organization
Organization Name:BRADFORD C SHINAMAN DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHINAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PA
Authorized Official - Phone:336-667-6081
Mailing Address - Street 1:PO BOX 606
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-0606
Mailing Address - Country:US
Mailing Address - Phone:336-667-6081
Mailing Address - Fax:
Practice Address - Street 1:406 8TH ST
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-4130
Practice Address - Country:US
Practice Address - Phone:336-667-6081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997781Medicaid