Provider Demographics
NPI:1194948745
Name:BRADLEY, JAMES RUSSELL (DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RUSSELL
Last Name:BRADLEY
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 1:3334 LONGMIRE DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-5812
Mailing Address - Country:US
Mailing Address - Phone:979-693-1511
Mailing Address - Fax:979-695-1403
Practice Address - Street 1:3334 LONGMIRE DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-5812
Practice Address - Country:US
Practice Address - Phone:979-693-1511
Practice Address - Fax:979-695-1403
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice