Provider Demographics
NPI:1811626898
Name:JEFFERSON, TAKIYA (DMD)
Entity Type:Individual
Prefix:
First Name:TAKIYA
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 S BOWMAN RD APT 14311
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4607
Mailing Address - Country:US
Mailing Address - Phone:501-554-5997
Mailing Address - Fax:
Practice Address - Street 1:11414 W MARKHAM ST STE A
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2847
Practice Address - Country:US
Practice Address - Phone:501-404-0529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AR4604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program