Provider Demographics
NPI:1043262744
Name:PHEN, JEFFREY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:PHEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 W MARCH LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6207
Mailing Address - Country:US
Mailing Address - Phone:209-474-0888
Mailing Address - Fax:209-474-3342
Practice Address - Street 1:850 W MARCH LN
Practice Address - Street 2:SUITE B
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6207
Practice Address - Country:US
Practice Address - Phone:209-474-0888
Practice Address - Fax:209-474-3342
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA449881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000604467OtherUNITED CONCORDIA
CAG91849Medicaid