Provider Demographics
NPI:1538361456
Name:BRADSHAW, CHARLES PEDIGO (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PEDIGO
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 CONWAY ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-2748
Mailing Address - Country:US
Mailing Address - Phone:502-223-4120
Mailing Address - Fax:502-223-4166
Practice Address - Street 1:220 CONWAY ST
Practice Address - Street 2:SUITE 2
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-2748
Practice Address - Country:US
Practice Address - Phone:502-223-4120
Practice Address - Fax:502-223-4166
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice