=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780741884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY A. ENGLESTADTER, DMD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2800 FOOTHILLS BLVD
-----------------------------------------------------
City | KLAMATH FALLS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97603-3768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-883-7409
-----------------------------------------------------
Fax | 541-850-8672
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2800 FOOTHILLS BLVD
-----------------------------------------------------
City | KLAMATH FALLS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97603-3768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-883-7409
-----------------------------------------------------
Fax | 541-850-8672
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JEFFREY A ENGLESTADTER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 541-883-7409
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | D7225
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------