Provider Demographics
NPI:1639239403
Name:WEYDERT, JENNIFER ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:WEYDERT
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 1:2900 THOMAS AVE S
Mailing Address - Street 2:APT 1907
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4477
Mailing Address - Country:US
Mailing Address - Phone:612-929-2590
Mailing Address - Fax:
Practice Address - Street 1:8980 HUDSON BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-9704
Practice Address - Country:US
Practice Address - Phone:651-735-9057
Practice Address - Fax:651-501-1471
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND121791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice