Provider Demographics
NPI:1801306493
Name:AZEVEDO, JENNIFER K (RDA, OSA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:K
Last Name:AZEVEDO
Suffix:
Gender:F
Credentials:RDA, OSA
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:K
Other - Last Name:BERGLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDA
Mailing Address - Street 1:201 E. ORANGEBURG AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:209-527-5050
Mailing Address - Fax:209-527-0659
Practice Address - Street 1:201 E ORANGEBURG AVE STE A
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5355
Practice Address - Country:US
Practice Address - Phone:209-527-5050
Practice Address - Fax:209-527-0659
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDS77618126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant