Provider Demographics
NPI:1366626764
Name:WEST, JEREMY THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:THOMAS
Last Name:WEST
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 1:1500 MCHENRY AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4529
Mailing Address - Country:US
Mailing Address - Phone:209-526-0462
Mailing Address - Fax:209-380-9223
Practice Address - Street 1:1500 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4529
Practice Address - Country:US
Practice Address - Phone:209-526-0462
Practice Address - Fax:209-526-9223
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA566691223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics