1508862277 NPI number — DR. JAY CLARKSON LUEDDE DDS

Table of content: DR. JAY CLARKSON LUEDDE DDS (NPI 1508862277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508862277 NPI number — DR. JAY CLARKSON LUEDDE DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUEDDE
Provider First Name:
JAY
Provider Middle Name:
CLARKSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508862277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
827 DEEP VALLEY DR
Provider Second Line Business Mailing Address:
STE 206
Provider Business Mailing Address City Name:
ROLLING HILLS ESTATES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90274-3654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-377-6944
Provider Business Mailing Address Fax Number:
310-541-4477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
827 DEEP VALLEY DR
Provider Second Line Business Practice Location Address:
STE 206
Provider Business Practice Location Address City Name:
ROLLING HILLS ESTATES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90274-3654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-377-6944
Provider Business Practice Location Address Fax Number:
310-541-4477
Provider Enumeration Date:
06/27/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  31314 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)