Provider Demographics
NPI:1144343906
Name:DAMON G BRADFORD DDS LTD
Entity type:Organization
Organization Name:DAMON G BRADFORD DDS LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:LILA
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALIMAA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-388-2630
Mailing Address - Street 1:2005 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201
Mailing Address - Country:US
Mailing Address - Phone:318-388-2630
Mailing Address - Fax:318-322-4537
Practice Address - Street 1:2005 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:318-388-2630
Practice Address - Fax:318-322-4537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty