Healthcare Provider Details

I. General information

NPI: 1487475737
Provider Name (Legal Business Name): BRADLEY T FREDERICK DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 APPLE BLOSSOM DR
FLOYDS KNOBS IN
47119-9025
US

IV. Provider business mailing address

1935 APPLE BLOSSOM DR
FLOYDS KNOBS IN
47119-9025
US

V. Phone/Fax

Practice location:
  • Phone: 502-552-4559
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BRADLEY FREDERICK
Title or Position: MANAGER
Credential: DMD
Phone: 502-552-4559