Provider Demographics
NPI:1154932150
Name:PAYNE, JACQUELINE MORGAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MORGAN
Last Name:PAYNE
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 1:1820 SONOMA AVE STE 36
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-6617
Mailing Address - Country:US
Mailing Address - Phone:707-546-5234
Mailing Address - Fax:
Practice Address - Street 1:1820 SONOMA AVE STE 36
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6617
Practice Address - Country:US
Practice Address - Phone:707-546-5234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1039191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty