Provider Demographics
NPI:1649213174
Name:PAYNE, JEFFREY CHRISTOPHER (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:CHRISTOPHER
Last Name:PAYNE
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756 PORTER AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-4232
Mailing Address - Country:US
Mailing Address - Phone:209-951-6387
Mailing Address - Fax:209-951-2824
Practice Address - Street 1:756 PORTER AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4232
Practice Address - Country:US
Practice Address - Phone:209-951-6387
Practice Address - Fax:209-951-2824
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA464191223S0112X
CAA89128204E00000X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93849-01OtherDENTICAL
CAV08402Medicare UPIN