Provider Demographics
NPI:1619231669
Name:BRADSHAW, RICHARD BRIAN (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BRIAN
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 1:3751 CALLE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9464
Mailing Address - Country:US
Mailing Address - Phone:801-367-1503
Mailing Address - Fax:801-367-1503
Practice Address - Street 1:4411 BROWN RIDGE TER
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9139
Practice Address - Country:US
Practice Address - Phone:541-200-6747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD100221223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program