Provider Demographics
NPI:1710198395
Name:ENGLESTADTER, JEFFREY A (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:ENGLESTADTER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 FOOTHILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-3768
Mailing Address - Country:US
Mailing Address - Phone:541-883-7409
Mailing Address - Fax:541-850-8672
Practice Address - Street 1:2800 FOOTHILLS BLVD
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-3768
Practice Address - Country:US
Practice Address - Phone:541-883-7409
Practice Address - Fax:541-850-8672
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7225122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist