Provider Demographics
NPI:1720215726
Name:CULLY, JENNIFER LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEE
Last Name:CULLY
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 1:3333 BURNET AVE
Mailing Address - Street 2:ML 2006
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4641
Mailing Address - Fax:513-636-8283
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 2006
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4641
Practice Address - Fax:513-636-8283
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1024102001223P0221X
PADS0384831223P0221X
OH30.0248991223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0256447Medicaid