Provider Demographics
NPI:1487030359
Name:BLOCK, JENNIFER (RDH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLOCK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 4TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371
Mailing Address - Country:US
Mailing Address - Phone:253-376-8545
Mailing Address - Fax:
Practice Address - Street 1:601 4TH AVE SW
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371
Practice Address - Country:US
Practice Address - Phone:253-376-8545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00004270124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist