Basic Information
| Provider Information | |||||||||
| NPI: | 1639131089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | C.B. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10076 | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914100076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055788950 | ||||||||
| Practice Location | |||||||||
| Address1: | 2730 SW MOODY AVE | ||||||||
| Address2: | SD-PATH | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972015042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948904 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 08/04/2014 | ||||||||
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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 | 1223S0112X | DF0006 | OR | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.