Provider Demographics
NPI:1639568843
Name:JOHN, JENNIFER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:JOHN
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 1:2100 OLD FARM DR STE 1-F
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-9494
Mailing Address - Country:US
Mailing Address - Phone:301-663-1700
Mailing Address - Fax:
Practice Address - Street 1:2100 OLD FARM DR STE 1-F
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702
Practice Address - Country:US
Practice Address - Phone:301-663-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15853122300000X
PADS040195122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist