Provider Demographics
NPI:1316938160
Name:FAULKNER, JEFFREY ALAN (MD, DDS)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
Last Name:FAULKNER
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 EAGLE CREEK RANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78114
Mailing Address - Country:US
Mailing Address - Phone:210-307-8051
Mailing Address - Fax:
Practice Address - Street 1:1600 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2813
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-01
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12726122300000X
PAMD064495L207Y00000X
TXP3319207Y00000X
NMMD2022-1352207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No122300000XDental ProvidersDentist