Provider Demographics
NPI:1184713505
Name:BRADLEY, JERRY L (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
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:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932
Mailing Address - Country:US
Mailing Address - Phone:252-482-1080
Mailing Address - Fax:252-482-1082
Practice Address - Street 1:512 COKE AVENUE
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932
Practice Address - Country:US
Practice Address - Phone:252-482-1080
Practice Address - Fax:252-482-1082
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5267122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist