Provider Demographics
NPI:1487762233
Name:HERRING, JERRY THOMAS (DDS)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:THOMAS
Last Name:HERRING
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 1:5308 LAKE MURRAY BLVD
Mailing Address - Street 2:STE D
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-1334
Mailing Address - Country:US
Mailing Address - Phone:619-465-6120
Mailing Address - Fax:619-465-4061
Practice Address - Street 1:5308 LAKE MURRAY BLVD
Practice Address - Street 2:STE D
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-1334
Practice Address - Country:US
Practice Address - Phone:619-465-6120
Practice Address - Fax:619-465-4061
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice