Provider Demographics
NPI:1568595023
Name:BLEDSOE, JACK DARRELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:DARRELL
Last Name:BLEDSOE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:8801 LYNNHURST DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3224
Mailing Address - Country:US
Mailing Address - Phone:703-280-2697
Mailing Address - Fax:703-280-2697
Practice Address - Street 1:9004 FERN PARK DR # A
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-1655
Practice Address - Country:US
Practice Address - Phone:703-978-0940
Practice Address - Fax:703-978-0941
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA04010030771223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics