Provider Demographics
NPI:1700308863
Name:BRADLEY M. WOODHAM, D.M.D., P.A.
Entity Type:Organization
Organization Name:BRADLEY M. WOODHAM, D.M.D., P.A.
Other - Org Name:EDGEWATER FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:239-481-6433
Mailing Address - Street 1:6120 WINKLER RD STE I
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8192
Mailing Address - Country:US
Mailing Address - Phone:239-481-6433
Mailing Address - Fax:
Practice Address - Street 1:6120 WINKLER RD STE I
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8192
Practice Address - Country:US
Practice Address - Phone:239-481-6433
Practice Address - Fax:239-481-6455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN171011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty