Provider Demographics
NPI:1740313881
Name:REDD, JERRY STANLEY (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:STANLEY
Last Name:REDD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:3470 LA CAMINITA
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-2312
Mailing Address - Country:US
Mailing Address - Phone:925-283-3242
Mailing Address - Fax:925-284-7457
Practice Address - Street 1:1620 VALLE VISTA AVE STE 200
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2887
Practice Address - Country:US
Practice Address - Phone:707-552-4940
Practice Address - Fax:707-552-7049
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA232361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics