Provider Demographics
NPI:1265518450
Name:STURDIVANT, JEFFREY J
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:J
Last Name:STURDIVANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 VALLEY WEST DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-3939
Mailing Address - Country:US
Mailing Address - Phone:515-225-9245
Mailing Address - Fax:515-225-8162
Practice Address - Street 1:125 VALLEY WEST DR
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-3939
Practice Address - Country:US
Practice Address - Phone:515-225-9245
Practice Address - Fax:515-225-8162
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA77361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics