Provider Demographics
NPI:1063470268
Name:DERSE, JENNIFER L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:DERSE
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 1:10630 N SCOTTSDALE RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254
Mailing Address - Country:US
Mailing Address - Phone:480-948-3680
Mailing Address - Fax:480-948-0711
Practice Address - Street 1:10630 N SCOTTSDALE RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254
Practice Address - Country:US
Practice Address - Phone:480-948-3680
Practice Address - Fax:480-948-0711
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ67011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice