Provider Demographics
NPI:1346357241
Name:CHILDRETH, JEFF E (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:E
Last Name:CHILDRETH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 CRATER LAKE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6213
Mailing Address - Country:US
Mailing Address - Phone:541-772-8846
Mailing Address - Fax:541-732-1878
Practice Address - Street 1:1150 CRATER LAKE AVE STE E
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6213
Practice Address - Country:US
Practice Address - Phone:541-772-8846
Practice Address - Fax:541-732-1878
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD77901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice