Provider Demographics
NPI:1881767051
Name:VANTREESE, JEFFERY R
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:R
Last Name:VANTREESE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-1507
Mailing Address - Country:US
Mailing Address - Phone:937-492-6984
Mailing Address - Fax:937-492-3802
Practice Address - Street 1:2627 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-1507
Practice Address - Country:US
Practice Address - Phone:937-492-6984
Practice Address - Fax:937-492-3802
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH184181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0659372Medicaid
OH31-1258173Medicare UPIN
OH0659372Medicaid