Healthcare Provider Details

I. General information

NPI: 1003048752
Provider Name (Legal Business Name): BRADFORD L PICOT, DDS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 08/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 SOUTH BLVD SUITE 110
CHARLOTTE NC
28203-4786
US

IV. Provider business mailing address

1520 SOUTH BLVD SUITE 110
CHARLOTTE NC
28203-4786
US

V. Phone/Fax

Practice location:
  • Phone: 704-335-8266
  • Fax: 704-335-8267
Mailing address:
  • Phone: 704-335-8266
  • Fax: 704-335-8267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8158
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number8158
License Number StateNC

VIII. Authorized Official

Name: DR. BRADFORD LEE PICOT
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 704-335-8266