Provider Demographics
NPI:1750454179
Name:JEFFERIES, MARK STEVEN JR (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
Last Name:JEFFERIES
Suffix:JR
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 1:2465 CENTREVILLE RD STE J15
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-3026
Mailing Address - Country:US
Mailing Address - Phone:703-793-1771
Mailing Address - Fax:
Practice Address - Street 1:2465 CENTREVILLE RD STE J15
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-3026
Practice Address - Country:US
Practice Address - Phone:703-793-1771
Practice Address - Fax:703-793-1789
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410740122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist