Provider Demographics
NPI:1558685339
Name:CASTANEDA-TAN, JEANNIFER P (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEANNIFER
Middle Name:P
Last Name:CASTANEDA-TAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18488
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-8488
Mailing Address - Country:US
Mailing Address - Phone:256-534-8659
Mailing Address - Fax:
Practice Address - Street 1:751 PLEASANT ROW NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35816-2537
Practice Address - Country:US
Practice Address - Phone:256-533-6311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLNO5735122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist