Provider Demographics
NPI:1952798878
Name:JERGENSEN DENTAL PC
Entity Type:Organization
Organization Name:JERGENSEN DENTAL PC
Other - Org Name:JERGENSEN DENTAL PC RODEO OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JERGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-413-8413
Mailing Address - Street 1:301 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:RODEO
Mailing Address - State:CA
Mailing Address - Zip Code:94572-1126
Mailing Address - Country:US
Mailing Address - Phone:510-799-4871
Mailing Address - Fax:
Practice Address - Street 1:301 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:RODEO
Practice Address - State:CA
Practice Address - Zip Code:94572-1126
Practice Address - Country:US
Practice Address - Phone:510-799-4871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JERGENSEN DENTAL PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59484122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty