Provider Demographics
NPI:1598758260
Name:GORDON-MALONEY, JENNIFER L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:GORDON-MALONEY
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 1:300 STONECREST BOULEVARD
Mailing Address - Street 2:SUITE 385
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-1200
Mailing Address - Country:US
Mailing Address - Phone:615-223-1200
Mailing Address - Fax:615-223-1090
Practice Address - Street 1:300 STONECREST BOULEVARD
Practice Address - Street 2:SUITE 385
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-1200
Practice Address - Country:US
Practice Address - Phone:615-223-1200
Practice Address - Fax:615-223-1090
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000074281223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN000000232437OtherUNITED HEALTHCARE ID#
TN4095527OtherBC/BS MEDICAL/DENTAL ID#
TN0015738OtherDORAL DENTAL OF TN ID#
TN272484OtherCIGNA DMO DENTAL ID #
TN3728862Medicaid
TNU90077Medicare UPIN
TN3728862Medicare ID - Type UnspecifiedMEDICARE ID #