Healthcare Provider Details

I. General information

NPI: 1699177048
Provider Name (Legal Business Name): DOUGLAS TRENT JEPSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 SAINT JOHN PLACE SUITE C
HEMET CA
92543
US

IV. Provider business mailing address

810 SAINT JOHN PLACE SUITE C
HEMET CA
92543
US

V. Phone/Fax

Practice location:
  • Phone: 951-652-4040
  • Fax: 951-652-4051
Mailing address:
  • Phone: 951-652-4040
  • Fax: 951-652-4051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number35509
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: