Provider Demographics
NPI:1841413465
Name:WALDEN, BRADLEY CLAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:CLAY
Last Name:WALDEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9053 TIMBERLANE RD
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568-9603
Mailing Address - Country:US
Mailing Address - Phone:715-892-7808
Mailing Address - Fax:
Practice Address - Street 1:450 OLD ABE RD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-9682
Practice Address - Country:US
Practice Address - Phone:715-588-4287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY83071223G0001X
WI62621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33825300Medicaid