Provider Demographics
NPI:1669143202
Name:SMITH, JENNA MARIE (RDH)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N15019 HANNAHVILLE B-1 RD
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:MI
Mailing Address - Zip Code:49896
Mailing Address - Country:US
Mailing Address - Phone:906-723-2508
Mailing Address - Fax:
Practice Address - Street 1:N15019 HANNAHVILLE B-1 RD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:MI
Practice Address - Zip Code:49896-4989
Practice Address - Country:US
Practice Address - Phone:906-723-2508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902016618124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist