Provider Demographics
NPI:1568895357
Name:REARDON, JENNIE O (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIE
Middle Name:O
Last Name:REARDON
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 1:9565 HIGHWAY 78
Mailing Address - Street 2:UNIT 600B
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9565 HIGHWAY 78
Practice Address - Street 2:UNIT 600B
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4118
Practice Address - Country:US
Practice Address - Phone:843-412-4036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC82651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice