Provider Demographics
NPI:1083697148
Name:JOE, JEFFREY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:JOE
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 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-6805
Mailing Address - Country:US
Mailing Address - Phone:209-383-1848
Mailing Address - Fax:209-384-3966
Practice Address - Street 1:1121 HAMMOND ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-3509
Practice Address - Country:US
Practice Address - Phone:209-576-4437
Practice Address - Fax:209-576-4494
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29831122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAJ1645641OtherDEA CERT