Provider Demographics
NPI:1467117101
Name:LA, JENNIFER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:LA
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 1:1201 PORTERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-1617
Mailing Address - Country:US
Mailing Address - Phone:682-365-3446
Mailing Address - Fax:
Practice Address - Street 1:1553 FARM TO MARKET 685 #400
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660
Practice Address - Country:US
Practice Address - Phone:512-989-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX379591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice