Provider Demographics
NPI:1952878357
Name:JENNIFER R THORNE PA
Entity Type:Organization
Organization Name:JENNIFER R THORNE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:THORNE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-281-4300
Mailing Address - Street 1:8300 PRECINCT LINE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-8242
Mailing Address - Country:US
Mailing Address - Phone:817-281-4300
Mailing Address - Fax:
Practice Address - Street 1:8300 PRECINCT LINE RD STE 100
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-8242
Practice Address - Country:US
Practice Address - Phone:817-281-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1023149374Medicaid