=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558194530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIMOTHY BRADBERRY DMD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2024
-----------------------------------------------------
Last Update Date | 08/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1566 DUNN AVE # 3
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32218-4734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-751-4958
-----------------------------------------------------
Fax | 904-751-5330
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1566 DUNN AVE # 3
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32218-4734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 904-751-5330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. TIMOTHY BRADBERRY
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 904-553-6474
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------