Provider Demographics
NPI:1588159263
Name:RENDON-VELASQUEZ, JENNIFFER (DMD)
Entity type:Individual
Prefix:DR
First Name:JENNIFFER
Middle Name:
Last Name:RENDON-VELASQUEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4027 SOUTHERN OAKS DR UNIT 2
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-0987
Mailing Address - Country:US
Mailing Address - Phone:201-478-1046
Mailing Address - Fax:
Practice Address - Street 1:3817 GRUBER RD
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-8925
Practice Address - Country:US
Practice Address - Phone:910-396-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI026911001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice