Provider Demographics
NPI:1114340700
Name:JESSE C. BRADFORD, D.D.S., P.L.L.C.
Entity Type:Organization
Organization Name:JESSE C. BRADFORD, D.D.S., P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-364-8685
Mailing Address - Street 1:319 S SHARON AMITY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2834
Mailing Address - Country:US
Mailing Address - Phone:704-364-8685
Mailing Address - Fax:704-364-8632
Practice Address - Street 1:319 S SHARON AMITY RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2834
Practice Address - Country:US
Practice Address - Phone:704-364-8685
Practice Address - Fax:704-364-8632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-02
Last Update Date:2014-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC87801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty