Healthcare Provider Details

I. General information

NPI: 1164431730
Provider Name (Legal Business Name): BRADFORD R THWEATT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 WHITESIDE RD
SANDSTON VA
23150-2345
US

IV. Provider business mailing address

5500 WHITESIDE RD
SANDSTON VA
23150-2345
US

V. Phone/Fax

Practice location:
  • Phone: 804-737-4444
  • Fax:
Mailing address:
  • Phone: 804-737-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401410887
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: