Provider Demographics
NPI:1952081051
Name:PELHAM, BRADLEY MYCHEL (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:MYCHEL
Last Name:PELHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 CALLE MONTEREY
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3943
Mailing Address - Country:US
Mailing Address - Phone:626-623-9449
Mailing Address - Fax:
Practice Address - Street 1:5665 HIGHWAY 95 N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86404-9646
Practice Address - Country:US
Practice Address - Phone:928-397-7007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDB-2023-0196122300000X
AZD011911122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist