MEDICARE: MARY SUSAN JENNINGS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4995	OK
2	1223G0001X	General Practice Dentistry	DE00007586	WA

General Provider Information

NPI Number	:	1740273432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY SUSAN JENNINGS DDS

Provider Business Mailing Address
First Line	:	1921 STONECIPHER DR
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-3439
Country	:	US
Telephone Number	:	580-436-3980
Fax Number	:

Provider Business Practice Location Address
First Line	:	1921 STONECIPHER DR
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-3439
Country	:	US
Telephone Number	:	580-436-3980
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	03/08/2019

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