Provider Demographics
NPI:1861855884
Name:BRADSHAW MOUNTAIN FAMILY DENTAL
Entity Type:Organization
Organization Name:BRADSHAW MOUNTAIN FAMILY DENTAL
Other - Org Name:BRADSHAW FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAUSTO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-775-9495
Mailing Address - Street 1:7136 PAV WAY
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-2264
Mailing Address - Country:US
Mailing Address - Phone:928-775-9495
Mailing Address - Fax:928-775-9497
Practice Address - Street 1:7136 PAV WAY
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2264
Practice Address - Country:US
Practice Address - Phone:928-775-9495
Practice Address - Fax:928-775-9497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ722183Medicaid