Provider Demographics
NPI:1558194530
Name:TIMOTHY BRADBERRY DMD, PLLC
Entity type:Organization
Organization Name:TIMOTHY BRADBERRY DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-553-6474
Mailing Address - Street 1:1566 DUNN AVE # 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:904-751-5330
Practice Address - Street 1:1566 DUNN AVE # 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4734
Practice Address - Country:US
Practice Address - Phone:904-751-4958
Practice Address - Fax:904-751-5330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty