Provider Demographics
NPI:1316147952
Name:JEFFRIES DENTAL, P.C.
Entity type:Organization
Organization Name:JEFFRIES DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST-CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:L. CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFRIES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-388-0137
Mailing Address - Street 1:3313 PAINTBRUSH LANE
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401
Mailing Address - Country:US
Mailing Address - Phone:307-347-3994
Mailing Address - Fax:307-347-3697
Practice Address - Street 1:3313 PAINTBRUSH LANE
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401
Practice Address - Country:US
Practice Address - Phone:307-347-3994
Practice Address - Fax:307-347-3697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10051223G0001X
WY10411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY113828600Medicaid
WY113370500Medicaid
WY113827800Medicaid
WY113829400Medicaid