Provider Demographics
NPI:1285749168
Name:JERGENSEN, TAL DEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:TAL
Middle Name:DEAN
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 1:27492 TIERRA VERDE DR
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-8480
Mailing Address - Country:US
Mailing Address - Phone:951-306-0620
Mailing Address - Fax:
Practice Address - Street 1:43980 MARGARITA RD STE 101
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-2783
Practice Address - Country:US
Practice Address - Phone:951-693-9373
Practice Address - Fax:951-699-9337
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA406211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics