Provider Demographics
NPI:1144795188
Name:JNR DENTAL
Entity Type:Organization
Organization Name:JNR DENTAL
Other - Org Name:TCG DENTAL SPECIALISTS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTFREDSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-909-1375
Mailing Address - Street 1:3640 MOSSY CREEK LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-3638
Mailing Address - Country:US
Mailing Address - Phone:850-228-7333
Mailing Address - Fax:
Practice Address - Street 1:2808 REMINGTON GREEN CIR STE 100
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-3724
Practice Address - Country:US
Practice Address - Phone:850-383-1052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty