Healthcare Provider Details

I. General information

NPI: 1952081051
Provider Name (Legal Business Name): BRADLEY MYCHEL PELHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 RIVIERA DR
LAKE HAVASU CITY AZ
86403-5736
US

IV. Provider business mailing address

3149 PALO VERDE BLVD N
LAKE HAVASU CITY AZ
86404-1470
US

V. Phone/Fax

Practice location:
  • Phone: 928-855-5061
  • Fax:
Mailing address:
  • Phone: 626-623-9449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD011911
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDB-2023-0196
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number109057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: