Healthcare Provider Details

I. General information

NPI: 1720181076
Provider Name (Legal Business Name): BRAD A TWADDLE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 CORONA RD STE 200
COLUMBIA MO
65203
US

IV. Provider business mailing address

3705 HUNTER VALLEY DR
COLUMBIA MO
65203
US

V. Phone/Fax

Practice location:
  • Phone: 573-234-2774
  • Fax:
Mailing address:
  • Phone: 573-445-7482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number015724
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: