Provider Demographics
NPI:1972626737
Name:BRADFORD, DAMON G JR (DDS)
Entity type:Individual
Prefix:DR
First Name:DAMON
Middle Name:G
Last Name:BRADFORD
Suffix:JR
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 1:2005 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201
Mailing Address - Country:US
Mailing Address - Phone:318-388-2630
Mailing Address - Fax:318-322-4537
Practice Address - Street 1:2005 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:318-388-2630
Practice Address - Fax:318-322-4537
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA27921223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics