Provider Demographics
NPI:1366577504
Name:STEWART, BRADLEY M (DMD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:M
Last Name:STEWART
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6855 CRUMPLER BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1938
Mailing Address - Country:US
Mailing Address - Phone:662-893-5800
Mailing Address - Fax:662-890-5614
Practice Address - Street 1:6855 CRUMPLER BLVD
Practice Address - Street 2:STE 100
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1938
Practice Address - Country:US
Practice Address - Phone:662-893-5800
Practice Address - Fax:662-890-5614
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3105-991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice