Healthcare Provider Details

I. General information

NPI: 1104819374
Provider Name (Legal Business Name): RONALD LEE JEFFREY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 EL NORTE PKWY #160
SAN MARCOS CA
92069-1773
US

IV. Provider business mailing address

PO BOX 1773
MAPLE FALLS WA
98266-1773
US

V. Phone/Fax

Practice location:
  • Phone: 360-296-3507
  • Fax:
Mailing address:
  • Phone: 360-296-3507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number53553
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: