Provider Demographics
NPI:1679960199
Name:BRADDENT LLC
Entity type:Organization
Organization Name:BRADDENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-467-6095
Mailing Address - Street 1:5075 HIGHWAY 31 UNIT B
Mailing Address - Street 2:
Mailing Address - City:CALERA
Mailing Address - State:AL
Mailing Address - Zip Code:35040-5165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5075 HIGHWAY 31 UNIT B
Practice Address - Street 2:
Practice Address - City:CALERA
Practice Address - State:AL
Practice Address - Zip Code:35040-5165
Practice Address - Country:US
Practice Address - Phone:334-467-6095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL55371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty