Provider Demographics
NPI:1194315135
Name:BRISTOL BARTLEY, PALOMA ANTONIA
Entity type:Individual
Prefix:DR
First Name:PALOMA
Middle Name:ANTONIA
Last Name:BRISTOL BARTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 W HUDSON BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-6430
Mailing Address - Country:US
Mailing Address - Phone:704-853-5191
Mailing Address - Fax:704-853-5131
Practice Address - Street 1:991 W HUDSON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-6430
Practice Address - Country:US
Practice Address - Phone:704-853-5191
Practice Address - Fax:704-853-5131
Is Sole Proprietor?:No
Enumeration Date:2021-01-23
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC136591223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program