Provider Demographics
NPI:1205962735
Name:HERRON, JENNIFER DIANE (DDS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:HERRON
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 1:14055 DAVENPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-3103
Mailing Address - Country:US
Mailing Address - Phone:858-484-4914
Mailing Address - Fax:
Practice Address - Street 1:215 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2710
Practice Address - Country:US
Practice Address - Phone:619-427-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30916122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA30916OtherDENTI-CAL