Provider Demographics
NPI:1205947439
Name:DERICKSON, JEFFREY CLINE (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:CLINE
Last Name:DERICKSON
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 1:762 N COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-4535
Mailing Address - Country:US
Mailing Address - Phone:520-327-5993
Mailing Address - Fax:520-327-0907
Practice Address - Street 1:762 N COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-4535
Practice Address - Country:US
Practice Address - Phone:520-327-5993
Practice Address - Fax:520-327-0907
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2369122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist