Provider Demographics
NPI:1518908771
Name:JACKSON, BRADFORD WILLIAMS (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:WILLIAMS
Last Name:JACKSON
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 1:509 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3565
Mailing Address - Country:US
Mailing Address - Phone:252-946-7725
Mailing Address - Fax:252-975-0272
Practice Address - Street 1:509 W 15TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3565
Practice Address - Country:US
Practice Address - Phone:252-946-7725
Practice Address - Fax:252-975-0272
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC79921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice