Provider Demographics
NPI:1396740023
Name:JENNINGS, DAVID R (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 W SUPERIOR ST
Mailing Address - Street 2:STE 720
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1721
Mailing Address - Country:US
Mailing Address - Phone:218-727-8994
Mailing Address - Fax:218-727-8995
Practice Address - Street 1:324 W SUPERIOR ST
Practice Address - Street 2:STE 720
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1721
Practice Address - Country:US
Practice Address - Phone:218-727-8994
Practice Address - Fax:218-727-8995
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN87611223S0112X
WI43740151223S0112X
WADE000065571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN761075OtherUNITED CONCORDIA PROVIDER
MN6B297JEOtherBC/BS OF MN GROUP #
MN6B298JEOtherBC/BS OF MN PROVIDER #
MNDB2954OtherRAILROAD MEDICARE GROUP #
MNHP38841OtherHEALTH PARTNERS
MNC03316Medicare ID - Type UnspecifiedMEDICARE GROUP #
MN761075OtherUNITED CONCORDIA PROVIDER