Provider Demographics
NPI:1952413049
Name:MAIN, JENNIFER ANN (DDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:MAIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:MCELLIGOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3102 INGERSOLL AVE.
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312
Mailing Address - Country:US
Mailing Address - Phone:515-279-0926
Mailing Address - Fax:515-279-5667
Practice Address - Street 1:3102 INGERSOLL AVE.
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312
Practice Address - Country:US
Practice Address - Phone:515-279-0926
Practice Address - Fax:515-279-5667
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08440122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0076372Medicare ID - Type Unspecified