Provider Demographics
NPI:1629164595
Name:JEFFREY J SUPPLE DMD, P.C.
Entity Type:Organization
Organization Name:JEFFREY J SUPPLE DMD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SUPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-883-3933
Mailing Address - Street 1:6800 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE G
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1405
Mailing Address - Country:US
Mailing Address - Phone:505-883-3933
Mailing Address - Fax:505-883-3934
Practice Address - Street 1:6800 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE G
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1405
Practice Address - Country:US
Practice Address - Phone:505-883-3933
Practice Address - Fax:505-883-3934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD17311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty