Provider Demographics
NPI:1356757462
Name:ISOM, BRADLEY
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:ISOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4329 BALL CAMP PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37921-3313
Mailing Address - Country:US
Mailing Address - Phone:865-521-7707
Mailing Address - Fax:
Practice Address - Street 1:4329 BALL CAMP PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37921-3313
Practice Address - Country:US
Practice Address - Phone:865-521-7707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008951122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist