Provider Demographics
NPI:1710550868
Name:LE, JENNIFER (DDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LE
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 1:628 LAURA LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2811
Mailing Address - Country:US
Mailing Address - Phone:469-261-9015
Mailing Address - Fax:
Practice Address - Street 1:2815 AZLE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76106-5106
Practice Address - Country:US
Practice Address - Phone:817-624-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX375171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice