Provider Demographics
NPI:1588893358
Name:MUNDEN, JENNY ILISHA (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNY
Middle Name:ILISHA
Last Name:MUNDEN
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 1:2428 N STONELAKE CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-1503
Mailing Address - Country:US
Mailing Address - Phone:317-695-0014
Mailing Address - Fax:
Practice Address - Street 1:494 S EMERSON AVE
Practice Address - Street 2:SUITE K
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1912
Practice Address - Country:US
Practice Address - Phone:317-882-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011327A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice