Provider Demographics
NPI:1679641260
Name:JENKINS, JUDITH G (DDS)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:G
Last Name:JENKINS
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:PO BOX 5395
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-5395
Mailing Address - Country:US
Mailing Address - Phone:505-984-5048
Mailing Address - Fax:505-983-4751
Practice Address - Street 1:1035 ALTO STREET
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87502-5395
Practice Address - Country:US
Practice Address - Phone:505-984-5048
Practice Address - Fax:505-983-4751
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD12391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9175776Medicaid
NMDD1239OtherDENTIST LICENSE NUMBER
NM1459740OtherUNITED CONCORDIA INS.
NM80341Medicaid