MEDICARE: JEFFREY JAMES SPROUT 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	7676	CO

General Provider Information

NPI Number	:	1922124049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY JAMES SPROUT DDS

Provider Business Mailing Address
First Line	:	32581 MEADOW MOUNTAIN RD
Second Line	:
City	:	EVERGREEN
State	:	CO
Zip	:	80439-9731
Country	:	US
Telephone Number	:	303-674-3542
Fax Number	:

Provider Business Practice Location Address
First Line	:	31226 LEWIS RIDGE RD
Second Line	:
City	:	EVERGREEN
State	:	CO
Zip	:	80439-7998
Country	:	US
Telephone Number	:	303-674-5566
Fax Number	:	303-674-8911

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

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	07/08/2007

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