Provider Demographics
NPI:1720499270
Name:FREDERICK, BRADLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-1042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:819 MOUNT TABOR RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6414
Practice Address - Country:US
Practice Address - Phone:812-945-7643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-17
Last Update Date:2014-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012118A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice