Provider Demographics
NPI:1205076668
Name:PERRY L. JEFFRIES DDS, PA
Entity type:Organization
Organization Name:PERRY L. JEFFRIES DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RELATIONS/FIN COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:BA DAII
Authorized Official - Phone:336-451-1957
Mailing Address - Street 1:1500 MOUNT ZION PL STE B
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3254
Mailing Address - Country:US
Mailing Address - Phone:336-748-0033
Mailing Address - Fax:336-748-0414
Practice Address - Street 1:1500 MOUNT ZION PL STE B
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3254
Practice Address - Country:US
Practice Address - Phone:336-748-0033
Practice Address - Fax:336-748-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC68321223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5907343Medicaid