Provider Demographics
NPI:1184790891
Name:WOODSIDE, JENNIFER LIEN (DDS)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LIEN
Last Name:WOODSIDE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:400 HOLIDAY COURT
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186
Mailing Address - Country:US
Mailing Address - Phone:540-341-0014
Mailing Address - Fax:540-341-0303
Practice Address - Street 1:400 HOLIDAY COURT
Practice Address - Street 2:SUITE 107
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186
Practice Address - Country:US
Practice Address - Phone:540-341-0014
Practice Address - Fax:540-341-0303
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA04014110061223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
186781OtherANTHEM
VA107966Medicaid
1777507OtherUNITED CONCORDIA DENTAL