Provider Demographics
NPI:1538729678
Name:JEFFRIES, CAROL L (DMD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:JEFFRIES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 MUSEUM BLVD UNIT 307
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-3194
Mailing Address - Country:US
Mailing Address - Phone:703-470-3791
Mailing Address - Fax:
Practice Address - Street 1:6300 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-4538
Practice Address - Country:US
Practice Address - Phone:224-214-4902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105209122300000X
IL019.032074122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist