Provider Demographics
NPI:1316027246
Name:MIKA, JEFFREY SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:MIKA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14570 MONO WAY STE M
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-8997
Mailing Address - Country:US
Mailing Address - Phone:209-532-1334
Mailing Address - Fax:209-532-7880
Practice Address - Street 1:14570 MONO WAY STE M
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-8997
Practice Address - Country:US
Practice Address - Phone:209-532-1334
Practice Address - Fax:209-532-7880
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB43039-01OtherCA HEALTHY FAMILY PROGRAM
CAB43039-01Medicaid