Basic Information
| Provider Information | |||||||||
| NPI: | 1285681635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFREY | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | CLINTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 ADRIATIC DR | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236641902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066233913 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2165 CUNNINGHAM DR | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236662569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578275665 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 0401410953 | VA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0401410953 | 01 | VA | STATE LICENSE | OTHER | 8555 | 01 | KY | KY DENTAL LICENSE | OTHER |