Healthcare Provider Details

I. General information

NPI: 1568625515
Provider Name (Legal Business Name): JEFFREY BRADFORD MOKRIS D.M.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 FIRST BAXTER XING SUITE 201
FORT MILL SC
29708-8948
US

IV. Provider business mailing address

3289 RICHARDS XING
FORT MILL SC
29708-8910
US

V. Phone/Fax

Practice location:
  • Phone: 803-547-0301
  • Fax:
Mailing address:
  • Phone: 803-818-0783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7002
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: