Healthcare Provider Details

I. General information

NPI: 1780972703
Provider Name (Legal Business Name): JEDEDIAH HUSS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 E AVENIDA DE LOS ARBOLES STE A
THOUSAND OAKS CA
91362-1392
US

IV. Provider business mailing address

1760 E AVENIDA DE LOS ARBOLES STE A
THOUSAND OAKS CA
91362-1392
US

V. Phone/Fax

Practice location:
  • Phone: 805-493-5200
  • Fax:
Mailing address:
  • Phone: 805-493-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number60491
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: