Provider Demographics
NPI:1710198551
Name:HALL, JON BRADLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:BRADLEY
Last Name:HALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 600577
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32260-0577
Mailing Address - Country:US
Mailing Address - Phone:904-491-8005
Mailing Address - Fax:904-491-8585
Practice Address - Street 1:5211 S FLETCHER AVE
Practice Address - Street 2:STE 230
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-5370
Practice Address - Country:US
Practice Address - Phone:904-491-8005
Practice Address - Fax:904-491-8585
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 129091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice