Provider Demographics
NPI:1225458714
Name:JERGENSEN DENTAL PC
Entity Type:Organization
Organization Name:JERGENSEN DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JERGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-413-8413
Mailing Address - Street 1:24 ALEXANDER ST
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-4609
Mailing Address - Country:US
Mailing Address - Phone:831-728-0232
Mailing Address - Fax:
Practice Address - Street 1:24 ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-4609
Practice Address - Country:US
Practice Address - Phone:831-728-0232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA594841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty