Provider Demographics
NPI:1427237874
Name:FAWAZ, JENNIFER LYNN (RDH)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:FAWAZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:ABBOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4102 PINION DR
Mailing Address - Street 2:10TH MEDICAL GROUP-SGDD
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840-2502
Mailing Address - Country:US
Mailing Address - Phone:719-333-5191
Mailing Address - Fax:
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:10TH MEDICAL GROUP-SGDD
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO904354124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist