Provider Demographics
NPI:1376808196
Name:DANIEL, JADA (DDS)
Entity Type:Individual
Prefix:
First Name:JADA
Middle Name:
Last Name:DANIEL
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 1:106 RANCHO VIEJO BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1553
Mailing Address - Country:US
Mailing Address - Phone:919-923-2721
Mailing Address - Fax:
Practice Address - Street 1:3569 ZAFARANO DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2618
Practice Address - Country:US
Practice Address - Phone:505-986-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9476122300000X
390200000X
NMDD5569122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program