Provider Demographics
NPI:1639267578
Name:STODDARD, JEREMIAH JOHNSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:JOHNSON
Last Name:STODDARD
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 1:721 COX CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1001
Mailing Address - Country:US
Mailing Address - Phone:256-766-9700
Mailing Address - Fax:256-766-0883
Practice Address - Street 1:721 COX CREEK PKWY
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1001
Practice Address - Country:US
Practice Address - Phone:256-766-9700
Practice Address - Fax:256-766-0883
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5097122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist