Provider Demographics
NPI:1205125242
Name:JERGENSEN, JUSTIN BURTON (DDS, MS)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:BURTON
Last Name:JERGENSEN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 KENT DR
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-0934
Mailing Address - Country:US
Mailing Address - Phone:415-407-1827
Mailing Address - Fax:
Practice Address - Street 1:1900 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3690
Practice Address - Country:US
Practice Address - Phone:707-422-3884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-30
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX262491223X0400X
CA63313122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist