Provider Demographics
NPI:1699954743
Name:VICENTE, JENNIFER ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:VICENTE
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 1:1157 PROFESSIONAL PARK DR
Mailing Address - Street 2:BUILDING #13
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4887
Mailing Address - Country:US
Mailing Address - Phone:734-604-9902
Mailing Address - Fax:
Practice Address - Street 1:1157 PROFESSIONAL PARK DR
Practice Address - Street 2:BUILDING #13
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4887
Practice Address - Country:US
Practice Address - Phone:734-604-9902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019676122300000X
FLDN 18243122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice