Healthcare Provider Details

I. General information

NPI: 1699894303
Provider Name (Legal Business Name): CHARLYN RAPPA BRADSHAW D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11211 PROSPERITY FARMS RD SUITE B107
PALM BEACH GARDENS FL
33410-3446
US

IV. Provider business mailing address

11211 PROSPERITY FARMS RD SUITE B107
PALM BEACH GARDENS FL
33410-3446
US

V. Phone/Fax

Practice location:
  • Phone: 561-630-8900
  • Fax: 561-828-0838
Mailing address:
  • Phone: 561-630-8900
  • Fax: 561-828-0838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN 13841
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: