Provider Demographics
NPI:1952553091
Name:PEDERSEN, JAC W II (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAC
Middle Name:W
Last Name:PEDERSEN
Suffix:II
Gender:M
Credentials:DDS
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Mailing Address - Street 1:3221 S HIGUERA ST
Mailing Address - Street 2:STE. 100
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6924
Mailing Address - Country:US
Mailing Address - Phone:805-544-8111
Mailing Address - Fax:805-544-6309
Practice Address - Street 1:3221 S HIGUERA ST
Practice Address - Street 2:STE. 100
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6924
Practice Address - Country:US
Practice Address - Phone:805-544-8111
Practice Address - Fax:805-544-6309
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
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Provider Licenses
StateLicense IDTaxonomies
CA274721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry