Healthcare Provider Details

I. General information

NPI: 1982670261
Provider Name (Legal Business Name): JAMES L. BRADSHAW DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 N MAIN ST
BLACKSTONE VA
23824-1423
US

IV. Provider business mailing address

131 NORTH MAIN STREET
BLACKSTONE VA
23824
US

V. Phone/Fax

Practice location:
  • Phone: 434-292-4665
  • Fax:
Mailing address:
  • Phone: 434-292-4665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4061
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: