Provider Demographics
NPI:1063471431
Name:JEFFERSON, JAY ALAN (DMD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:ALAN
Last Name:JEFFERSON
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 1:8301 BANDFORD WAY
Mailing Address - Street 2:SUITE 121
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-2767
Mailing Address - Country:US
Mailing Address - Phone:919-876-4746
Mailing Address - Fax:919-876-5071
Practice Address - Street 1:8301 BANDFORD WAY
Practice Address - Street 2:SUITE 121
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-2767
Practice Address - Country:US
Practice Address - Phone:919-876-4746
Practice Address - Fax:919-876-5071
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5669122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
94549OtherBCBS
NC8994549Medicaid
NC8994549Medicaid
241376AMedicare ID - Type Unspecified