Provider Demographics
NPI:1679379655
Name:BRIDGEFORTH, TAMISHA L (RDA & DLT)
Entity type:Individual
Prefix:
First Name:TAMISHA
Middle Name:L
Last Name:BRIDGEFORTH
Suffix:
Gender:
Credentials:RDA & DLT
Other - Prefix:
Other - First Name:TAMISHA
Other - Middle Name:L
Other - Last Name:BRIDGEFORTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1768 PENDLETON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38114-7803
Mailing Address - Country:US
Mailing Address - Phone:901-828-0784
Mailing Address - Fax:
Practice Address - Street 1:1768 PENDLETON ST APT 3
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38114-7803
Practice Address - Country:US
Practice Address - Phone:901-828-0784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN126900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes126900000XDental ProvidersDental Laboratory TechnicianGroup - Single Specialty