Provider Demographics
NPI:1386836427
Name:HARRELSON, BRADLEY DALE (DMD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DALE
Last Name:HARRELSON
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 1:4400 E HIGHWAY 20 STE 111
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-9735
Mailing Address - Country:US
Mailing Address - Phone:850-897-4171
Mailing Address - Fax:850-897-4622
Practice Address - Street 1:4400 E HIGHWAY 20 STE 111
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-9735
Practice Address - Country:US
Practice Address - Phone:850-897-4171
Practice Address - Fax:850-897-4622
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3428-07122300000X
MSOS-519-161223S0112X
FLDN247991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist