Provider Demographics
NPI:1366756991
Name:AGUSTIN, JEFFREY JASON (DMD)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:JASON
Last Name:AGUSTIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3005
Mailing Address - Country:US
Mailing Address - Phone:909-825-0545
Mailing Address - Fax:909-825-5101
Practice Address - Street 1:251 E VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3005
Practice Address - Country:US
Practice Address - Phone:909-825-0545
Practice Address - Fax:909-825-5101
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49799122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist