Provider Demographics
NPI:1730319302
Name:BRADFORD, JESSE CAMPBELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:CAMPBELL
Last Name:BRADFORD
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 1:319 S SHARON AMITY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2834
Mailing Address - Country:US
Mailing Address - Phone:704-534-0528
Mailing Address - Fax:
Practice Address - Street 1:319 S SHARON AMITY RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2834
Practice Address - Country:US
Practice Address - Phone:704-534-0528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-17
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC87801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice