Provider Demographics
NPI:1437519758
Name:JEPPSEN, JOHN RYAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RYAN
Last Name:JEPPSEN
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 1:4411 SAN MATEO BLVD NE STE E1
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2000
Mailing Address - Country:US
Mailing Address - Phone:505-872-4867
Mailing Address - Fax:972-590-8809
Practice Address - Street 1:4411 SAN MATEO BLVD NE STE E1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-872-4867
Practice Address - Fax:505-872-9380
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NM58091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program