Provider Demographics
NPI:1841276573
Name:JENKINS, DALE CR (DDS)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:CR
Last Name:JENKINS
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 1:2145 CAJA DEL ORO GRANT RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3279
Mailing Address - Country:US
Mailing Address - Phone:505-474-1438
Mailing Address - Fax:505-424-5699
Practice Address - Street 1:2145 CAJA DEL ORO GRANT RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3279
Practice Address - Country:US
Practice Address - Phone:505-474-1438
Practice Address - Fax:505-424-5699
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2097122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9179749Medicaid
NMDD2097OtherDENTAL LICENSE