Provider Demographics
NPI:1740577352
Name:CAVANAUGH, JENNIFER L (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:SENGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:3032 VIA RIALTO ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-5412
Mailing Address - Country:US
Mailing Address - Phone:412-370-3634
Mailing Address - Fax:
Practice Address - Street 1:1111 N PARKWAY FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-0400
Practice Address - Country:US
Practice Address - Phone:863-644-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-03
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038741122300000X
FLDN199621223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist