Provider Demographics
NPI:1558530097
Name:JOHN C JEPPESEN DMD INC
Entity Type:Organization
Organization Name:JOHN C JEPPESEN DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEPPESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-644-2270
Mailing Address - Street 1:178 S VICTORIA AVE
Mailing Address - Street 2:SUITE C & D
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-4329
Mailing Address - Country:US
Mailing Address - Phone:805-644-2270
Mailing Address - Fax:805-644-2576
Practice Address - Street 1:178 S VICTORIA AVE
Practice Address - Street 2:SUITE C & D
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-4329
Practice Address - Country:US
Practice Address - Phone:805-644-2270
Practice Address - Fax:805-644-2576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QS1200X
332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
4693420001Medicare NSC