Provider Demographics
NPI:1821358474
Name:BROCKETT, JEFFREY EASTMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:EASTMAN
Last Name:BROCKETT
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 1:6755 MONTERRA TRL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-1343
Mailing Address - Country:US
Mailing Address - Phone:323-632-3361
Mailing Address - Fax:
Practice Address - Street 1:7776 IVANHOE AVE STE 100
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4575
Practice Address - Country:US
Practice Address - Phone:858-454-1468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA614011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice