Healthcare Provider Details

I. General information

NPI: 1528441003
Provider Name (Legal Business Name): JEFFREY DENTAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 GLEN AVE
VALPARAISO FL
32580-1233
US

IV. Provider business mailing address

304 GLEN AVE
VALPARAISO FL
32580-1233
US

V. Phone/Fax

Practice location:
  • Phone: 850-678-4151
  • Fax:
Mailing address:
  • Phone: 850-678-4151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MCKINZIE DAWN JEFFREY
Title or Position: OWNER
Credential: DDS
Phone: 850-678-4151