Provider Demographics
NPI:1841505757
Name:BRADBERRY, LINH TRUONG (DMD)
Entity type:Individual
Prefix:
First Name:LINH
Middle Name:TRUONG
Last Name:BRADBERRY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LINH
Other - Middle Name:MY
Other - Last Name:TRUONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:5911 TIMUQUANA RD STE 202
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-8174
Mailing Address - Country:US
Mailing Address - Phone:904-993-6088
Mailing Address - Fax:904-993-6088
Practice Address - Street 1:10915 BAYMEADOWS RD STE 106
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9131
Practice Address - Country:US
Practice Address - Phone:904-619-6478
Practice Address - Fax:904-580-4262
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19050122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN19050OtherSTATE DENTAL LICENSE