Provider Demographics
NPI:1104391341
Name:GAZZOLA, JENNA L (DMD, MA)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:L
Last Name:GAZZOLA
Suffix:
Gender:F
Credentials:DMD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 W WICKENBURG WAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-2262
Mailing Address - Country:US
Mailing Address - Phone:928-684-5475
Mailing Address - Fax:
Practice Address - Street 1:1175 W WICKENBURG WAY
Practice Address - Street 2:SUITE 1
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-2262
Practice Address - Country:US
Practice Address - Phone:928-684-5475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI27156001223G0001X
AZD0116901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice