Provider Demographics
NPI:1407119837
Name:JEFFUS, JUSTIN ZACKARY (DMD)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ZACKARY
Last Name:JEFFUS
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:PO BOX 2867
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36652-2867
Mailing Address - Country:US
Mailing Address - Phone:251-690-8158
Mailing Address - Fax:251-544-2188
Practice Address - Street 1:950 W COY SMITH HWY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:AL
Practice Address - Zip Code:36560-3201
Practice Address - Country:US
Practice Address - Phone:251-829-9884
Practice Address - Fax:251-829-9507
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5934 CI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL011846OtherMEDICARE GROUP NUMBER
AL1063439065OtherPAYEE NPI GROUP NUMBER
AL630000013Medicaid