Healthcare Provider Details

I. General information

NPI: 1215084546
Provider Name (Legal Business Name): BLAIR ANDREW BRADFORD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11671 JOLLYVILLE RD STE 201
AUSTIN TX
78759-4141
US

IV. Provider business mailing address

11671 JOLLYVILLE RD STE 201
AUSTIN TX
78759-4141
US

V. Phone/Fax

Practice location:
  • Phone: 512-249-7668
  • Fax: 512-219-1246
Mailing address:
  • Phone: 512-249-7668
  • Fax: 512-219-1246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number22027
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: