Provider Demographics
NPI:1598776304
Name:JEPSEN, CARL H (DDS, PHD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:H
Last Name:JEPSEN
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4632 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4842
Mailing Address - Country:US
Mailing Address - Phone:619-298-2229
Mailing Address - Fax:619-298-5959
Practice Address - Street 1:306 WALNUT AVE STE 39
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4936
Practice Address - Country:US
Practice Address - Phone:619-298-2229
Practice Address - Fax:619-298-5959
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA187121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice