Provider Demographics
NPI:1790232296
Name:RORY S. JEFFERSON, DDS
Entity Type:Organization
Organization Name:RORY S. JEFFERSON, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-479-2440
Mailing Address - Street 1:797 NE RIDDELL RD
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3030
Mailing Address - Country:US
Mailing Address - Phone:360-479-2440
Mailing Address - Fax:360-479-7769
Practice Address - Street 1:797 NE RIDDELL RD.
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3030
Practice Address - Country:US
Practice Address - Phone:360-479-2440
Practice Address - Fax:360-479-7769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA8158122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty