Healthcare Provider Details

I. General information

NPI: 1467574665
Provider Name (Legal Business Name): BRUCE R JESPERSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10430 S DE ANZA BLVD STE 290
CUPERTINO CA
95014-3025
US

IV. Provider business mailing address

10430 S DE ANZA BLVD STE 290
CUPERTINO CA
95014-3025
US

V. Phone/Fax

Practice location:
  • Phone: 408-446-5787
  • Fax: 408-446-1447
Mailing address:
  • Phone: 408-446-5787
  • Fax: 408-446-1447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number27152
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: