Provider Demographics
NPI:1902334600
Name:KILLEBREW, BRADLEY JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JAMES
Last Name:KILLEBREW
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11439 SPRING CREEK DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1919
Mailing Address - Country:US
Mailing Address - Phone:985-981-1040
Mailing Address - Fax:
Practice Address - Street 1:1116 S PURPERA AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4361
Practice Address - Country:US
Practice Address - Phone:225-647-3577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA67461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice