Provider Demographics
NPI:1154605384
Name:JDM DENTAL, PLC
Entity type:Organization
Organization Name:JDM DENTAL, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAURER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-748-8677
Mailing Address - Street 1:4516 W HUNDRED RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-1740
Mailing Address - Country:US
Mailing Address - Phone:804-909-5709
Mailing Address - Fax:804-748-8053
Practice Address - Street 1:4516 W HUNDRED RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1740
Practice Address - Country:US
Practice Address - Phone:804-909-5709
Practice Address - Fax:804-748-8053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411812122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty