Provider Demographics
NPI:1154638500
Name:JEFFERSON DENTAL
Entity Type:Organization
Organization Name:JEFFERSON DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SYEDA
Authorized Official - Middle Name:SHABNAM
Authorized Official - Last Name:HUQ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-775-0600
Mailing Address - Street 1:79800 HIGHWAY 111 STE 109
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-6003
Mailing Address - Country:US
Mailing Address - Phone:760-775-0600
Mailing Address - Fax:760-775-0663
Practice Address - Street 1:79800 HIGHWAY 111 STE 109
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-6003
Practice Address - Country:US
Practice Address - Phone:760-775-0600
Practice Address - Fax:760-775-0663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA569711223G0001X
CA444841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861669533Medicaid
CA1861612954Medicaid