Provider Demographics
NPI:1912271164
Name:CARPENTER, BRADLEY WAYNE (DMD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:WAYNE
Last Name:CARPENTER
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:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-0446
Mailing Address - Country:US
Mailing Address - Phone:503-655-7250
Mailing Address - Fax:503-650-6375
Practice Address - Street 1:15480 SE 82ND DR
Practice Address - Street 2:
Practice Address - City:CLACAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015
Practice Address - Country:US
Practice Address - Phone:503-655-7250
Practice Address - Fax:503-650-6375
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD54941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice