Provider Demographics
NPI:1851553390
Name:JENKINS, JERRY LEWIS (DDS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LEWIS
Last Name:JENKINS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 CROWDER DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-4237
Mailing Address - Country:US
Mailing Address - Phone:804-794-7845
Mailing Address - Fax:804-794-3568
Practice Address - Street 1:1009 CROWDER DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-4237
Practice Address - Country:US
Practice Address - Phone:804-794-8745
Practice Address - Fax:804-794-3568
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3746122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist