Provider Demographics
NPI:1003510793
Name:JENNELL, KATHERINE BURTS (RDH)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:BURTS
Last Name:JENNELL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:RENEE
Other - Last Name:BURTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2809 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23222-3647
Mailing Address - Country:US
Mailing Address - Phone:804-944-4504
Mailing Address - Fax:804-329-1206
Practice Address - Street 1:719 N 25TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-6539
Practice Address - Country:US
Practice Address - Phone:804-780-0840
Practice Address - Fax:804-329-1206
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402003276124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty