Provider Demographics
NPI:1962118992
Name:RUEDA, JENNIFER PATRICIA (DMD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PATRICIA
Last Name:RUEDA
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 1:400 CALLAWALK CT APT 302
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33896-5554
Mailing Address - Country:US
Mailing Address - Phone:786-955-5507
Mailing Address - Fax:
Practice Address - Street 1:120 CARTER BLVD STE 7
Practice Address - Street 2:
Practice Address - City:POLK CITY
Practice Address - State:FL
Practice Address - Zip Code:33868-8912
Practice Address - Country:US
Practice Address - Phone:863-984-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN27460122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist