Provider Demographics
NPI:1265766315
Name:JUSON, JEREMIAH EDILLOR (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:EDILLOR
Last Name:JUSON
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 1:360 E 89TH ST APT 5B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5418
Mailing Address - Country:US
Mailing Address - Phone:212-803-3345
Mailing Address - Fax:
Practice Address - Street 1:2301 QUEENS PLZ N STE C
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101
Practice Address - Country:US
Practice Address - Phone:508-679-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL11820122300000X, 1223X0400X
NY0596131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAF6873803#4OtherDEA NO