Provider Demographics
NPI:1598992588
Name:DANIEL, JENNIFER T (DDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:T
Last Name:DANIEL
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 1:6353 E PEA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2525
Mailing Address - Country:US
Mailing Address - Phone:304-736-4794
Mailing Address - Fax:304-736-1135
Practice Address - Street 1:6353 E PEA RIDGE RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2525
Practice Address - Country:US
Practice Address - Phone:304-736-4794
Practice Address - Fax:304-736-1135
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4013122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810023810Medicaid
KY7100208310Medicaid
OH0068952Medicaid