Provider Demographics
NPI:1609144997
Name:O'MALLEY, JENNI MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNI
Middle Name:MARIE
Last Name:O'MALLEY
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 1:1374 CATTAIL PT
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-9404
Mailing Address - Country:US
Mailing Address - Phone:407-791-7997
Mailing Address - Fax:
Practice Address - Street 1:1105 W STONE DR STE 5
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-2558
Practice Address - Country:US
Practice Address - Phone:423-224-5697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27456122300000X, 1223G0001X
TN11246122300000X
FL21809122300000X
SC8896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice