Provider Demographics
NPI:1710105648
Name:JEFFERY, CARL RAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:RAY
Last Name:JEFFERY
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 1:685 FOX RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-2471
Mailing Address - Country:US
Mailing Address - Phone:419-238-5810
Mailing Address - Fax:419-238-9802
Practice Address - Street 1:685 FOX RD
Practice Address - Street 2:SUITE 103
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-2471
Practice Address - Country:US
Practice Address - Phone:419-238-5810
Practice Address - Fax:419-238-9802
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH143821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice