Provider Demographics
NPI:1134673056
Name:BRADBERRY, TIMOTHY (DMD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:BRADBERRY
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 1:1566 DUNN AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4734
Mailing Address - Country:US
Mailing Address - Phone:904-751-4958
Mailing Address - Fax:904-751-5330
Practice Address - Street 1:7301 MERRILL RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-3726
Practice Address - Country:US
Practice Address - Phone:904-743-3114
Practice Address - Fax:904-743-2955
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22149122300000X
FLDN221491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist