Basic Information
Provider Information | |||||||||
NPI: | 1841252269 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JEFFALONE | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | MALCOLM | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2776 RINGGOLD ROAD | ||||||||
Address2: | FORT SILL DENTAL ACTIVITY | ||||||||
City: | FORT SILL | ||||||||
State: | OK | ||||||||
PostalCode: | 73503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5804423905 | ||||||||
FaxNumber: | 5804424002 | ||||||||
Practice Location | |||||||||
Address1: | DENTAC 2410 STANLEY ROAD | ||||||||
Address2: | SUITE 200J | ||||||||
City: | FORT SAM HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 782346230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2102952743 | ||||||||
FaxNumber: | 2102952602 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2006 | ||||||||
LastUpdateDate: | 02/16/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 20740 | TX | Y |   | Dental Providers | Dentist |   | 1223G0001X | 043037 | NY | N |   | Dental Providers | Dentist | General Practice |
No ID Information.