Provider Demographics
NPI:1184725830
Name:JEFFERS, KEVIN TODD (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:TODD
Last Name:JEFFERS
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 1:3829 MOSS HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-1567
Mailing Address - Country:US
Mailing Address - Phone:707-542-1942
Mailing Address - Fax:707-528-0316
Practice Address - Street 1:3912 PRINCETON DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7014
Practice Address - Country:US
Practice Address - Phone:707-528-6343
Practice Address - Fax:707-528-0316
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA519421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice