Provider Demographics
NPI:1811431331
Name:TENNY, JASON (DDS)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:TENNY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10239 SW VILLAGE PKWY APT 206
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2364
Mailing Address - Country:US
Mailing Address - Phone:703-389-3891
Mailing Address - Fax:
Practice Address - Street 1:10696 SW VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2358
Practice Address - Country:US
Practice Address - Phone:772-380-4490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 223781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice