Provider Demographics
NPI:1629172812
Name:JERRY BRADLEY DDS AND ASSOCIATES PLLC
Entity Type:Organization
Organization Name:JERRY BRADLEY DDS AND ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:252-482-1080
Mailing Address - Street 1:PO BOX 552
Mailing Address - Street 2:512 COKE AVENUE
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-0552
Mailing Address - Country:US
Mailing Address - Phone:252-482-1080
Mailing Address - Fax:252-482-1082
Practice Address - Street 1:512 COKE AVE
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-1539
Practice Address - Country:US
Practice Address - Phone:252-482-1080
Practice Address - Fax:252-482-1082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC52671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7990844Medicaid
NC7990844Medicaid