Healthcare Provider Details

I. General information

NPI: 1437110012
Provider Name (Legal Business Name): JED LEDESMA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 NE JACKSON ST
GRANTS PASS OR
97526-1644
US

IV. Provider business mailing address

118 NE JACKSON ST
GRANTS PASS OR
97526-1644
US

V. Phone/Fax

Practice location:
  • Phone: 541-476-4511
  • Fax: 541-479-9006
Mailing address:
  • Phone: 541-476-4511
  • Fax: 541-479-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD8489
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: