MEDICARE: DR. WALTER JEFFERSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	53460	CA

General Provider Information

NPI Number	:	1134239544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALTER JEFFERSON DDS

Provider Business Mailing Address
First Line	:	2860 MICHELLE
Second Line	:	2ND FLOOR
City	:	IRVINE
State	:	CA
Zip	:	92606-1009
Country	:	US
Telephone Number	:	714-508-3600
Fax Number	:	714-368-2092

Provider Business Practice Location Address
First Line	:	3297 ARLINGTON AVE
Second Line	:	STE. 101
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3249
Country	:	US
Telephone Number	:	951-683-6055
Fax Number	:	951-683-5819

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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