Provider Demographics
NPI:1881608347
Name:BACK, JENIFER C (DMD)
Entity type:Individual
Prefix:DR
First Name:JENIFER
Middle Name:C
Last Name:BACK
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 1:3800 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-2361
Mailing Address - Country:US
Mailing Address - Phone:941-927-5411
Mailing Address - Fax:941-927-5477
Practice Address - Street 1:3800 CLARK RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-2361
Practice Address - Country:US
Practice Address - Phone:941-927-5411
Practice Address - Fax:941-927-5477
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 141691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice