Provider Demographics
NPI:1679761662
Name:CRANDALL, JENNIFER LOUISE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LOUISE
Last Name:CRANDALL
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 1:18740 VENTURA BLVD
Mailing Address - Street 2:#305
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3366
Mailing Address - Country:US
Mailing Address - Phone:818-609-1777
Mailing Address - Fax:818-609-9352
Practice Address - Street 1:18740 VENTURA BLVD
Practice Address - Street 2:#305
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3366
Practice Address - Country:US
Practice Address - Phone:818-609-1777
Practice Address - Fax:818-609-9352
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030778122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist