Provider Demographics
NPI:1437122959
Name:WOODWORTH, JEFFREY D (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:WOODWORTH
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 1:2274 WEDNESDAY ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4334
Mailing Address - Country:US
Mailing Address - Phone:850-309-0970
Mailing Address - Fax:850-205-4052
Practice Address - Street 1:2274 WEDNESDAY ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4334
Practice Address - Country:US
Practice Address - Phone:850-309-0970
Practice Address - Fax:850-205-4052
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN102041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU26369Medicare ID - Type Unspecified