Provider Demographics
NPI:1669875381
Name:KM JEFFERS DENTAL CORP
Entity type:Organization
Organization Name:KM JEFFERS DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:P
Authorized Official - Last Name:JEFFERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-462-2993
Mailing Address - Street 1:1119 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6426
Mailing Address - Country:US
Mailing Address - Phone:707-462-2993
Mailing Address - Fax:707-462-3999
Practice Address - Street 1:1119 S STATE ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-6426
Practice Address - Country:US
Practice Address - Phone:707-462-2993
Practice Address - Fax:707-462-3999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA626281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty