Provider Demographics
NPI:1316119373
Name:JENKINS DENTAL GROUP
Entity type:Organization
Organization Name:JENKINS DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-393-4361
Mailing Address - Street 1:3349 PORTSMOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23701-3023
Mailing Address - Country:US
Mailing Address - Phone:757-393-4361
Mailing Address - Fax:757-393-3738
Practice Address - Street 1:3349 PORTSMOUTH BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701-3023
Practice Address - Country:US
Practice Address - Phone:757-393-4361
Practice Address - Fax:757-393-3738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA32441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty