Provider Demographics
NPI:1356444384
Name:JACOBS, BRADLEY JOHN (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JOHN
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1005 EXECUTIVE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-7903
Mailing Address - Country:US
Mailing Address - Phone:423-877-1286
Mailing Address - Fax:423-877-1290
Practice Address - Street 1:1005 EXECUTIVE DR
Practice Address - Street 2:SUITE 105
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-7903
Practice Address - Country:US
Practice Address - Phone:423-877-1286
Practice Address - Fax:423-877-1290
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNDS87421223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics