Basic Information
| Provider Information | |||||||||
| NPI: | 1437700952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WALTER JEFFERSON DENTAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17000 RED HILL AVE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926145626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458890 | ||||||||
| FaxNumber: | 3039520892 | ||||||||
| Practice Location | |||||||||
| Address1: | 962 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | HARBOR CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907101405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105393245 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2019 | ||||||||
| LastUpdateDate: | 09/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | JEFFERSON | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3105393245 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.