=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700308863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRADLEY M. WOODHAM, D.M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6120 WINKLER RD STE I
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33919-8192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-481-6433
-----------------------------------------------------
Fax | 239-481-6455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6120 WINKLER RD STE I
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33919-8192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-481-6433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BRADLEY WOODHAM
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 239-481-6433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN17101
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------