Provider Demographics
NPI:1932864634
Name:BRADFORD LEGACY DENTAL
Entity Type:Organization
Organization Name:BRADFORD LEGACY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDERON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-655-4867
Mailing Address - Street 1:4158 SWANS LNDG
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-4239
Mailing Address - Country:US
Mailing Address - Phone:210-655-4867
Mailing Address - Fax:
Practice Address - Street 1:4158 SWANS LNDG
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-4239
Practice Address - Country:US
Practice Address - Phone:210-655-4867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1831602796OtherNPI
TX1396831681OtherNPI