Provider Demographics
NPI:1336271543
Name:CAPES, JEFFREY OLIVER (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:OLIVER
Last Name:CAPES
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 OFFICE PARK LN STE 104
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-6604
Mailing Address - Country:US
Mailing Address - Phone:912-634-6600
Mailing Address - Fax:912-634-3882
Practice Address - Street 1:110 OFFICE PARK LANE
Practice Address - Street 2:SUITE 104
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-3152
Practice Address - Country:US
Practice Address - Phone:912-634-6600
Practice Address - Fax:912-634-3882
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0115151223G0001X
GA0457811223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
U72240Medicare UPIN