Provider Demographics
NPI:1063426518
Name:JERGENSEN, RICHARD F (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:F
Last Name:JERGENSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 QUAIL RUN
Mailing Address - Street 2:B-1
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6307
Mailing Address - Country:US
Mailing Address - Phone:541-973-2983
Mailing Address - Fax:707-422-1702
Practice Address - Street 1:11 ROSSANLEY DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-1713
Practice Address - Country:US
Practice Address - Phone:541-973-2983
Practice Address - Fax:707-422-1702
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27771122300000X
ORD9422122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist