Provider Demographics
NPI:1437252509
Name:PERSICO, JEFFREY E (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:E
Last Name:PERSICO
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 1:4451 SATINWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3074
Mailing Address - Country:US
Mailing Address - Phone:517-831-0813
Mailing Address - Fax:
Practice Address - Street 1:5238 W ST JOE HWY
Practice Address - Street 2:SUITE 2
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-4085
Practice Address - Country:US
Practice Address - Phone:517-323-1000
Practice Address - Fax:517-886-5566
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010156691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M51220Medicare PIN