Provider Demographics
NPI:1710407606
Name:JURGENSMEIER, BRADLEY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:R
Last Name:JURGENSMEIER
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 1:4902 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28470-4749
Mailing Address - Country:US
Mailing Address - Phone:910-754-8289
Mailing Address - Fax:
Practice Address - Street 1:4902 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4749
Practice Address - Country:US
Practice Address - Phone:910-754-8289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009785122300000X
NC12154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist