Provider Demographics
NPI:1396844221
Name:JONES, DEMETRA CORRINE (DDS)
Entity Type:Individual
Prefix:
First Name:DEMETRA
Middle Name:CORRINE
Last Name:JONES
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 1:3408 SILVERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75233-2614
Mailing Address - Country:US
Mailing Address - Phone:214-337-5847
Mailing Address - Fax:214-565-7952
Practice Address - Street 1:4432 MALCOLM X BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215-4349
Practice Address - Country:US
Practice Address - Phone:214-565-4330
Practice Address - Fax:214-565-7952
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX193401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009457501Medicaid