Provider Demographics
NPI:1306912373
Name:MATOUSEK-RONCK, JENNIFER MANE (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MANE
Last Name:MATOUSEK-RONCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 E EMMA AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-4634
Mailing Address - Country:US
Mailing Address - Phone:479-751-7417
Mailing Address - Fax:479-751-4898
Practice Address - Street 1:614 E EMMA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-4634
Practice Address - Country:US
Practice Address - Phone:479-751-7417
Practice Address - Fax:479-751-4898
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5876122300000X
AR3815122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200086130AMedicaid
AR198665608Medicaid