Provider Demographics
NPI:1578827127
Name:RICHARDS, JENNA MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:MARIE
Last Name:RICHARDS
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 1:4718 ORLANDO CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228-2907
Mailing Address - Country:US
Mailing Address - Phone:317-418-1503
Mailing Address - Fax:
Practice Address - Street 1:760 EAST AVE BLDG 3911
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32508-5136
Practice Address - Country:US
Practice Address - Phone:850-452-8970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011841A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist