Provider Demographics
NPI:1093167041
Name:STANDAGE, JEFFREY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:STANDAGE
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 1:104 MEDICINE WAY
Mailing Address - Street 2:
Mailing Address - City:PERIDOT
Mailing Address - State:AZ
Mailing Address - Zip Code:85542-0000
Mailing Address - Country:US
Mailing Address - Phone:928-475-1480
Mailing Address - Fax:
Practice Address - Street 1:104 MEDICINE WAY
Practice Address - Street 2:
Practice Address - City:PERIDOT
Practice Address - State:AZ
Practice Address - Zip Code:85542-0000
Practice Address - Country:US
Practice Address - Phone:928-475-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist