Provider Demographics
NPI:1619450327
Name:POPE, JEREMY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:LEE
Last Name:POPE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5828 ARBORLAWN DR APT 1310
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-3256
Mailing Address - Country:US
Mailing Address - Phone:817-657-3476
Mailing Address - Fax:
Practice Address - Street 1:4200 BRYANT IRVIN RD STE 101
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76109-4212
Practice Address - Country:US
Practice Address - Phone:817-657-3476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-09
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34527122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist