Provider Demographics
NPI:1821648486
Name:HAWKINS, BRADLEY THOMAS-TERROLL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:THOMAS-TERROLL
Last Name:HAWKINS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:BRADLEY
Other - Middle Name:THOMAS-TERROLL
Other - Last Name:HAWKINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:95-390 KUAHELANI
Mailing Address - Street 2:3AC-1193
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-1192
Mailing Address - Country:US
Mailing Address - Phone:808-201-9273
Mailing Address - Fax:
Practice Address - Street 1:95-390 KUAHELANI
Practice Address - Street 2:3AC-1193
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-1192
Practice Address - Country:US
Practice Address - Phone:808-201-9273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2022-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171431223G0001X
390200000X
HIDT-2880-01223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD265063100Medicaid
15743316OtherCAQH ID