Healthcare Provider Details

I. General information

NPI: 1124697990
Provider Name (Legal Business Name): WEST DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1236 FLOYD AVE STE C
MODESTO CA
95350-2472
US

IV. Provider business mailing address

1500 MCHENRY AVE
MODESTO CA
95350-4529
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-5515
  • Fax:
Mailing address:
  • Phone: 209-526-0462
  • Fax: 209-526-9223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JEREMY THOMAS WEST
Title or Position: PRESIDENT
Credential: DDS
Phone: 209-526-0462