Provider Demographics
NPI:1962713057
Name:FOGLE, JAY BRADFORD (DDS)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:BRADFORD
Last Name:FOGLE
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 1:14643 CENTRAL VALLEY RD NW
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-8167
Mailing Address - Country:US
Mailing Address - Phone:206-992-4148
Mailing Address - Fax:
Practice Address - Street 1:1275 NE FRANKLIN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-3005
Practice Address - Country:US
Practice Address - Phone:360-377-0803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601402781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice