Provider Demographics
NPI:1376745299
Name:JEFFERS, GARY EDWIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:EDWIN
Last Name:JEFFERS
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 1:8200 W OUTER DR
Mailing Address - Street 2:ORAL SURGERY CLINIC
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-3580
Mailing Address - Country:US
Mailing Address - Phone:313-494-6739
Mailing Address - Fax:313-494-6666
Practice Address - Street 1:42890 STEEPLEVIEW ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-2077
Practice Address - Country:US
Practice Address - Phone:734-420-1127
Practice Address - Fax:734-420-0926
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010124371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice