Provider Demographics
NPI:1639169634
Name:JONES, JERRY L (MD DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
Last Name:JONES
Suffix:
Gender:M
Credentials:MD DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 CUBERO DR NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3882
Mailing Address - Country:US
Mailing Address - Phone:505-797-3530
Mailing Address - Fax:505-797-2155
Practice Address - Street 1:5900 CUBERO DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3882
Practice Address - Country:US
Practice Address - Phone:505-797-3530
Practice Address - Fax:505-797-2155
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM85-2181223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84335Medicaid
NME1446Medicaid
T40802Medicare UPIN
NM2203236Medicare ID - Type Unspecified