Provider Demographics
NPI:1295862357
Name:BRADLEY, JERRY E (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:E
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1225 BRECKENRIDGE DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-1558
Mailing Address - Country:US
Mailing Address - Phone:501-225-4644
Mailing Address - Fax:501-225-4102
Practice Address - Street 1:1225 BRECKENRIDGE DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-225-4644
Practice Address - Fax:501-225-4102
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR121223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics