Provider Demographics
NPI:1831119940
Name:BRADDY, JARAD JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:JARAD
Middle Name:JOSEPH
Last Name:BRADDY
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 1:8747 NORTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-2409
Mailing Address - Country:US
Mailing Address - Phone:662-393-0781
Mailing Address - Fax:662-342-0750
Practice Address - Street 1:8747 NORTHWEST DR
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-2409
Practice Address - Country:US
Practice Address - Phone:662-393-0781
Practice Address - Fax:662-342-0750
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3341-051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060134Medicaid