Provider Demographics
NPI:1679721054
Name:BRADLEY, CHADWYCK R (DMD)
Entity type:Individual
Prefix:DR
First Name:CHADWYCK
Middle Name:R
Last Name:BRADLEY
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 1:2050 A SECOND ST SE
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND AFB
Mailing Address - State:NM
Mailing Address - Zip Code:87117-0001
Mailing Address - Country:US
Mailing Address - Phone:505-846-3027
Mailing Address - Fax:
Practice Address - Street 1:2050 A SECOND STREET SE
Practice Address - Street 2:
Practice Address - City:KIRTLAND AFB
Practice Address - State:NM
Practice Address - Zip Code:87117-5153
Practice Address - Country:US
Practice Address - Phone:505-846-3027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58624122300000X
AZD7651122300000X
NMDD3940122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist