Provider Demographics
NPI:1447469622
Name:BRANTLEY, JAMES WALLACE JR (DMD)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:WALLACE
Last Name:BRANTLEY
Suffix:JR
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 1:5685 HWY 18 WEST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-9622
Mailing Address - Country:US
Mailing Address - Phone:603-373-2404
Mailing Address - Fax:601-373-4443
Practice Address - Street 1:5685 HWY 18 WEST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-9622
Practice Address - Country:US
Practice Address - Phone:603-373-2404
Practice Address - Fax:601-373-4443
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1794781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice