Provider Demographics
NPI:1417569385
Name:MINK, JENNIFER (DDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MINK
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 1:1800 N HALL ST APT 441
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-4152
Mailing Address - Country:US
Mailing Address - Phone:618-363-4242
Mailing Address - Fax:
Practice Address - Street 1:101 N FM 548 STE 105
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-5686
Practice Address - Country:US
Practice Address - Phone:972-552-1224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX366051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice