Provider Demographics
NPI:1053676684
Name:DAVIES, JENNA MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:DAVIES
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 1:9850 E 79TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-4822
Mailing Address - Country:US
Mailing Address - Phone:317-288-5388
Mailing Address - Fax:317-288-5412
Practice Address - Street 1:9850 E 79TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256
Practice Address - Country:US
Practice Address - Phone:317-288-5388
Practice Address - Fax:317-288-5412
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INLDR1200161223G0001X
IN12012035A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice