Provider Demographics
NPI:1790206423
Name:POWERS, JEREMY TAYLOR (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:TAYLOR
Last Name:POWERS
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 1:29950 HAUN RD STE 302
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92586-6527
Mailing Address - Country:US
Mailing Address - Phone:951-679-1667
Mailing Address - Fax:
Practice Address - Street 1:29950 HAUN RD STE 302
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92586-6527
Practice Address - Country:US
Practice Address - Phone:951-679-1667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1013491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice