Healthcare Provider Details

I. General information

NPI: 1952394421
Provider Name (Legal Business Name): JOHN C JEPPESEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 01/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 S VICTORIA AVE STE C
VENTURA CA
93003-4369
US

IV. Provider business mailing address

178 S VICTORIA AVE STE C
VENTURA CA
93003-4369
US

V. Phone/Fax

Practice location:
  • Phone: 805-644-2270
  • Fax: 805-644-2576
Mailing address:
  • Phone: 805-644-2270
  • Fax: 805-644-2576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number31638
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number31638
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: