Provider Demographics
NPI:1972631059
Name:MANEEPETASUT, JEFFRIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFRIE
Middle Name:
Last Name:MANEEPETASUT
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 1:4606 HOLLYWOOD BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5462
Mailing Address - Country:US
Mailing Address - Phone:617-312-5663
Mailing Address - Fax:
Practice Address - Street 1:4606 HOLLYWOOD BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5462
Practice Address - Country:US
Practice Address - Phone:617-312-5663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53468122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist