Healthcare Provider Details

I. General information

NPI: 1558419945
Provider Name (Legal Business Name): PHILIP A BRADFORD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 UNIVERSITY AVE
RIVERSIDE CA
92507-5202
US

IV. Provider business mailing address

8151 ARLINGTON AVE STE U-V
RIVERSIDE CA
92503-0436
US

V. Phone/Fax

Practice location:
  • Phone: 951-276-0668
  • Fax: 951-328-9578
Mailing address:
  • Phone: 951-588-0861
  • Fax: 951-588-1910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19329
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: