Provider Demographics
NPI:1447240825
Name:JEFFERSON, BETHANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BETHANIEL
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:BETHANIEL
Other - Middle Name:S
Other - Last Name:JEFFERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:15531 KUYKENDAHL RD
Mailing Address - Street 2:180
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-3645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15531 KUYKENDAHL RD
Practice Address - Street 2:180
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-3645
Practice Address - Country:US
Practice Address - Phone:281-895-7787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice