Provider Demographics
NPI:1336242700
Name:NEISE, JENNIFER A (DDS)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:A
Last Name:NEISE
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 1:3132 W. STATE ROAD 38
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064
Mailing Address - Country:US
Mailing Address - Phone:765-778-7585
Mailing Address - Fax:765-778-0795
Practice Address - Street 1:3132 W. STATE ROAD 38
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064
Practice Address - Country:US
Practice Address - Phone:765-778-7585
Practice Address - Fax:765-778-0795
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010223A122300000X
IND12010223A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200525580Medicaid