MEDICARE: OATES AND JEFFERSON DENTAL CORPORATION

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

General Provider Information

NPI Number	:	1174961536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OATES AND JEFFERSON DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	17000 RED HILL AVE
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92614-5626
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	949-474-1495

Provider Business Practice Location Address
First Line	:	1559 PACIFIC COAST HWY
Second Line	:	SUITE 101
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-3214
Country	:	US
Telephone Number	:	310-372-7686
Fax Number	:	310-372-7692

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WALTER JEFFERSON
Credential	:	DDS
Telephone Number	:	310-372-7686

Provider Enumeration Date	:	06/07/2013
Last Update Date	:	06/07/2013

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