Provider Demographics
NPI:1164470050
Name:WESTBROOK, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:WESTBROOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 379
Mailing Address - Street 2:
Mailing Address - City:QUEMADO
Mailing Address - State:NM
Mailing Address - Zip Code:87829
Mailing Address - Country:US
Mailing Address - Phone:505-773-4322
Mailing Address - Fax:
Practice Address - Street 1:PINE HILL DENTAL CLINIC
Practice Address - Street 2:BIA ROUTE 125
Practice Address - City:PINE HILL
Practice Address - State:NM
Practice Address - Zip Code:87357
Practice Address - Country:US
Practice Address - Phone:505-775-3271
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD24261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice