Healthcare Provider Details

I. General information

NPI: 1356522205
Provider Name (Legal Business Name): JACK WILLIAM REDMOND II DDS MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 WEST GONZALES ROAD SUITE 320
OXNARD CA
93036
US

IV. Provider business mailing address

451 WEST GONZALES ROAD SUITE 320
OXNARD CA
93036
US

V. Phone/Fax

Practice location:
  • Phone: 805-485-5150
  • Fax: 805-485-5780
Mailing address:
  • Phone: 805-485-5150
  • Fax: 805-485-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number23456
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: