Provider Demographics
NPI:1215323506
Name:DELVASTO, JENNYFER
Entity type:Individual
Prefix:
First Name:JENNYFER
Middle Name:
Last Name:DELVASTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 NW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3421
Mailing Address - Country:US
Mailing Address - Phone:479-531-3459
Mailing Address - Fax:
Practice Address - Street 1:9856 E LOUISIANA DR
Practice Address - Street 2:APT 208
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80247-2390
Practice Address - Country:US
Practice Address - Phone:479-531-3459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012584A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist