Healthcare Provider Details

I. General information

NPI: 1144619057
Provider Name (Legal Business Name): JEFFREY JON JEPPERSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 POPE AVE US ARMY DENTAL ACTIVTY
FORT LEAVENWORTH KS
66027-2332
US

IV. Provider business mailing address

520 POPE AVE US ARMY DENTAL ACTIVTY
FORT LEAVENWORTH KS
66027-2332
US

V. Phone/Fax

Practice location:
  • Phone: 913-684-5516
  • Fax:
Mailing address:
  • Phone: 913-684-5516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9039485-9922
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number61083
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: