Provider Demographics
NPI:1124401146
Name:CANADA MCKNIGHT, JENNIFER (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CANADA MCKNIGHT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:CANADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:6725 N. 35TH AVE., #105
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017
Mailing Address - Country:US
Mailing Address - Phone:602-595-5230
Mailing Address - Fax:602-595-5280
Practice Address - Street 1:3387 HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-6900
Practice Address - Country:US
Practice Address - Phone:678-813-2388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ97961223P0221X
390200000X
GADN1230351223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty