Provider Demographics
NPI:1851500748
Name:BAILEY, JOHN THERON (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THERON
Last Name:BAILEY
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 1:917 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1650
Mailing Address - Country:US
Mailing Address - Phone:321-723-0938
Mailing Address - Fax:
Practice Address - Street 1:917 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1650
Practice Address - Country:US
Practice Address - Phone:321-723-0938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9970122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist