Provider Demographics
NPI:1265988059
Name:LAURENCE, JENNIFER NICOLE (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:NICOLE
Last Name:LAURENCE
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 1:4006 BEAUBIEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-2896
Mailing Address - Country:US
Mailing Address - Phone:210-381-5366
Mailing Address - Fax:
Practice Address - Street 1:2500 VILLAGE DR STE 101
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3982
Practice Address - Country:US
Practice Address - Phone:910-424-3623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX378591223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice