Provider Demographics
NPI:1013395185
Name:JENNINGS, ANDREA (DMD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:JENNINGS
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:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:CO
Mailing Address - Zip Code:80435-0158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 MAIN ST.
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:CO
Practice Address - Zip Code:80435
Practice Address - Country:US
Practice Address - Phone:970-468-2471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30-24805122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program