Basic Information
Provider Information | |||||||||
NPI: | 1932255882 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JEFFRIES | ||||||||
FirstName: | PERRY | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 871 HUFFMAN ST | ||||||||
Address2: |   | ||||||||
City: | GREENSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 274057205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3362300346 | ||||||||
FaxNumber: | 3362300348 | ||||||||
Practice Location | |||||||||
Address1: | 871 HUFFMAN ST | ||||||||
Address2: |   | ||||||||
City: | GREENSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 274057205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3362300346 | ||||||||
FaxNumber: | 3362300348 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 6832 | NC | Y |   | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
ID | Type | State | Issuer | Description | 7990132 | 05 | NC |   | MEDICAID | 8990132 | 05 | NC |   | MEDICAID | 5900485 | 05 | NC |   | MEDICAID |