Provider Demographics
NPI:1669539292
Name:PEZOLDT, BRAD EDWARD (DDS MSD)
Entity type:Individual
Prefix:DR
First Name:BRAD
Middle Name:EDWARD
Last Name:PEZOLDT
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 ALSACE LN
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8945
Mailing Address - Country:US
Mailing Address - Phone:209-524-2988
Mailing Address - Fax:
Practice Address - Street 1:1316 COFFEE RD STE D10
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3191
Practice Address - Country:US
Practice Address - Phone:209-524-2988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA412061223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics