Provider Demographics
NPI:1811444201
Name:HAINES, JEREMY JAMES (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JAMES
Last Name:HAINES
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19372 HIGHRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-1628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19372 HIGHRIDGE WAY
Practice Address - Street 2:
Practice Address - City:TRABUCO CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679-1628
Practice Address - Country:US
Practice Address - Phone:801-735-7461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-02
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1005531223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics