Provider Demographics
NPI:1255492674
Name:THALLER, JEFFREY SPENCER (DMD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SPENCER
Last Name:THALLER
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 1:104 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-2427
Mailing Address - Country:US
Mailing Address - Phone:908-654-7050
Mailing Address - Fax:908-654-4452
Practice Address - Street 1:104 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-2427
Practice Address - Country:US
Practice Address - Phone:908-654-7050
Practice Address - Fax:908-654-4452
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI015693001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice