Provider Demographics
NPI:1013654912
Name:BATES, BRENDA J (CRDH)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:J
Last Name:BATES
Suffix:
Gender:F
Credentials:CRDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 739
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32008-0739
Mailing Address - Country:US
Mailing Address - Phone:386-364-8526
Mailing Address - Fax:
Practice Address - Street 1:619 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5808
Practice Address - Country:US
Practice Address - Phone:386-155-3016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14857124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist