Healthcare Provider Details

I. General information

NPI: 1124195250
Provider Name (Legal Business Name): BRADLEY MATTHEW FARROW DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 TRADERS WAY SUITE 300
THOMPSONS STATION TN
37179-5366
US

IV. Provider business mailing address

4720 TRADERS WAY SUITE 300
THOMPSONS STATION TN
37179-5366
US

V. Phone/Fax

Practice location:
  • Phone: 615-595-1559
  • Fax: 615-595-9945
Mailing address:
  • Phone: 615-595-1559
  • Fax: 615-595-9945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN012381
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: