Provider Demographics
NPI:1932371093
Name:KING, JEREMY MALCOLM (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:MALCOLM
Last Name:KING
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 1:4005 NICHOLSON DR
Mailing Address - Street 2:APT #2613
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-8402
Mailing Address - Country:US
Mailing Address - Phone:303-815-7896
Mailing Address - Fax:
Practice Address - Street 1:4005 NICHOLSON DR
Practice Address - Street 2:APT #2613
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-8402
Practice Address - Country:US
Practice Address - Phone:303-815-7896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-29
Last Update Date:2008-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAS502122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist