Provider Demographics
NPI:1932296514
Name:GILBERT FARNHAM, JACQUELENE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELENE
Middle Name:
Last Name:GILBERT FARNHAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11528 SAN JOSE BLVD
Mailing Address - Street 2:
Mailing Address - City:MANDARIN
Mailing Address - State:FL
Mailing Address - Zip Code:32223
Mailing Address - Country:US
Mailing Address - Phone:904-262-2551
Mailing Address - Fax:904-262-2930
Practice Address - Street 1:11528 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:MANDARIN
Practice Address - State:FL
Practice Address - Zip Code:32223
Practice Address - Country:US
Practice Address - Phone:904-262-2551
Practice Address - Fax:904-262-2930
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0008863122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist