Provider Demographics
NPI:1487642641
Name:HUMBERSON, JEFFREY WADE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WADE
Last Name:HUMBERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490B W ZIA RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7008
Mailing Address - Country:US
Mailing Address - Phone:505-428-7878
Mailing Address - Fax:
Practice Address - Street 1:490B W ZIA RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7008
Practice Address - Country:US
Practice Address - Phone:505-428-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002031251223P0221X
MD118101223P0221X
NMDD21561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000A9157Medicaid