Provider Demographics
NPI:1720269947
Name:PHILIP, JEREL FREDERIC (DMD)
Entity Type:Individual
Prefix:
First Name:JEREL
Middle Name:FREDERIC
Last Name:PHILIP
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 1:4100 PORTOLA DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062
Mailing Address - Country:US
Mailing Address - Phone:831-475-7739
Mailing Address - Fax:831-475-7782
Practice Address - Street 1:4100 PORTOLA DR
Practice Address - Street 2:SUITE 1
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062
Practice Address - Country:US
Practice Address - Phone:831-475-7739
Practice Address - Fax:831-475-7782
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA381591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice