Provider Demographics
NPI:1679723712
Name:DAUPHIN, JEROMY WADE (DDS)
Entity type:Individual
Prefix:DR
First Name:JEROMY
Middle Name:WADE
Last Name:DAUPHIN
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 1:1024 SW 104TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-2990
Mailing Address - Country:US
Mailing Address - Phone:405-691-1123
Mailing Address - Fax:405-691-2674
Practice Address - Street 1:1024 SW 104TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-2990
Practice Address - Country:US
Practice Address - Phone:405-691-1123
Practice Address - Fax:405-691-2674
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24108122300000X
OK6141122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist