MEDICARE: DR. BLAIR ANDREW BRADFORD DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	22027	TX

General Provider Information

NPI Number	:	1215084546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAIR ANDREW BRADFORD DMD

Provider Business Mailing Address
First Line	:	11671 JOLLYVILLE RD STE 201
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-4141
Country	:	US
Telephone Number	:	512-249-7668
Fax Number	:	512-219-1246

Provider Business Practice Location Address
First Line	:	11671 JOLLYVILLE RD STE 201
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-4141
Country	:	US
Telephone Number	:	512-249-7668
Fax Number	:	512-219-1246

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	07/08/2007

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