Provider Demographics
NPI:1912205790
Name:DAVIS, C. BRADLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:C.
Middle Name:BRADLEY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 EXECUTIVE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-7911
Mailing Address - Country:US
Mailing Address - Phone:423-876-0408
Mailing Address - Fax:423-876-0410
Practice Address - Street 1:1017 EXECUTIVE DR STE 102
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-7911
Practice Address - Country:US
Practice Address - Phone:423-876-0408
Practice Address - Fax:423-876-0410
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN79841223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics