Provider Demographics
NPI:1215079801
Name:SANTOS, JENNIFER VENGCO (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:VENGCO
Last Name:SANTOS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:VENGCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3516 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1156
Mailing Address - Country:US
Mailing Address - Phone:818-957-4403
Mailing Address - Fax:
Practice Address - Street 1:3516 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1156
Practice Address - Country:US
Practice Address - Phone:818-957-4403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA494031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice