Healthcare Provider Details

I. General information

NPI: 1639655129
Provider Name (Legal Business Name): JEFFREY BRUMBAUGH DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12121 WILSHIRE BLVD STE 1111
LOS ANGELES CA
90025-1188
US

IV. Provider business mailing address

2100 TOMICH RD
HACIENDA HEIGHTS CA
91745-6817
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-0588
  • Fax:
Mailing address:
  • Phone: 626-536-6650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDDS102107
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: