MEDICARE: DR. JEFFREY L EZEKIEL 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	0401007624	VA

General Provider Information

NPI Number	:	1639278203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY L EZEKIEL DDS

Provider Business Mailing Address
First Line	:	3301 HAMPTON HWY
Second Line	:	SUITE M
City	:	YORKTOWN
State	:	VA
Zip	:	23693
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3301 HAMPTON HWY
Second Line	:	SUITE M
City	:	YORKTOWN
State	:	VA
Zip	:	23693
Country	:	US
Telephone Number	:	757-867-5003
Fax Number	:	757-867-5006

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/08/2007

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