Healthcare Provider Details

I. General information

NPI: 1790781623
Provider Name (Legal Business Name): BRADFORD FAMILY DENTISTRY, PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 WEST CALL STREET
STARKE FL
32091-3113
US

IV. Provider business mailing address

315 W CALL ST
STARKE FL
32091-3113
US

V. Phone/Fax

Practice location:
  • Phone: 904-964-7501
  • Fax: 904-964-7503
Mailing address:
  • Phone: 904-964-7501
  • Fax: 904-964-7503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN 07445
License Number StateFL

VIII. Authorized Official

Name: DR. WILLIAM MARCHESE
Title or Position: PARTNER
Credential: D.M.D., R.PH.
Phone: 904-964-7501