Provider Demographics
NPI:1326429077
Name:ENSLEY, JOHN R (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:ENSLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39710
Mailing Address - Country:US
Mailing Address - Phone:662-434-2258
Mailing Address - Fax:
Practice Address - Street 1:2133 PEPPERRELL ST BLDG 3352
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5313
Practice Address - Country:US
Practice Address - Phone:210-292-9054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014957122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist