Provider Demographics
NPI:1073609020
Name:SUPPLE, JEFFREY J (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:J
Last Name:SUPPLE
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 1:6800 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE G
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1405
Mailing Address - Country:US
Mailing Address - Phone:505-883-3933
Mailing Address - Fax:505-883-3934
Practice Address - Street 1:6800 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE G
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1405
Practice Address - Country:US
Practice Address - Phone:505-883-3933
Practice Address - Fax:505-883-3934
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD17311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice