Provider Demographics
NPI:1598968810
Name:FRUIN, JEFFREY W (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:FRUIN
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 1:3257 CAMINO DE LOS COCHES
Mailing Address - Street 2:#306
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009
Mailing Address - Country:US
Mailing Address - Phone:760-634-8100
Mailing Address - Fax:760-634-8130
Practice Address - Street 1:3257 CAMINO DE LOS COCHES
Practice Address - Street 2:#306
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009
Practice Address - Country:US
Practice Address - Phone:760-634-8100
Practice Address - Fax:760-634-8130
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0344891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6459180001Medicare NSC