Provider Demographics
NPI:1477073732
Name:PEREDA, JENIFFER (DMD)
Entity type:Individual
Prefix:
First Name:JENIFFER
Middle Name:
Last Name:PEREDA
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 1:2010 S JUNIPER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-5509
Mailing Address - Country:US
Mailing Address - Phone:215-334-3490
Mailing Address - Fax:
Practice Address - Street 1:2010 S JUNIPER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-5509
Practice Address - Country:US
Practice Address - Phone:215-334-3490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041418122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist