Provider Demographics
NPI:1114015708
Name:HUSTON, JEFF (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:
Last Name:HUSTON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 RIVER MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:95258-9312
Mailing Address - Country:US
Mailing Address - Phone:209-369-5548
Mailing Address - Fax:
Practice Address - Street 1:1300 W LODI AVE
Practice Address - Street 2:SUITE M
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3000
Practice Address - Country:US
Practice Address - Phone:209-333-0374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA312851223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry