Provider Demographics
NPI:1205197399
Name:EMDADI, JENNIFER ROCHELLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ROCHELLE
Last Name:EMDADI
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 1:1301 COATES BLUFF DR
Mailing Address - Street 2:APT#622
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2841
Mailing Address - Country:US
Mailing Address - Phone:951-533-2534
Mailing Address - Fax:
Practice Address - Street 1:510 E. STONER AVE
Practice Address - Street 2:OVERTON BROOKS VA MEDICAL CENTER
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADO NOT APPLY1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice