Provider Demographics
NPI:1851644322
Name:HETHERINGTON, BRADLEY EARL (RDH)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:EARL
Last Name:HETHERINGTON
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2458 WESTCLIFFE LN
Mailing Address - Street 2:#A
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-3280
Mailing Address - Country:US
Mailing Address - Phone:925-457-9620
Mailing Address - Fax:
Practice Address - Street 1:2458 WESTCLIFFE LN
Practice Address - Street 2:#A
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-3280
Practice Address - Country:US
Practice Address - Phone:925-457-9620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27013124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist