Provider Demographics
NPI:1124287693
Name:COLEMAN, BRADLEY WAYNE (DDS)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:WAYNE
Last Name:COLEMAN
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 1:2338 HIGHWAY 62 W
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-6184
Mailing Address - Country:US
Mailing Address - Phone:870-424-4670
Mailing Address - Fax:870-425-4674
Practice Address - Street 1:2338 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-6184
Practice Address - Country:US
Practice Address - Phone:870-424-4670
Practice Address - Fax:870-425-4764
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3663122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist