Healthcare Provider Details

I. General information

NPI: 1518148436
Provider Name (Legal Business Name): JENNIFER VIRGINIA NATION D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 BARTON RD
REDLANDS CA
92373-1410
US

IV. Provider business mailing address

1510 BARTON RD
REDLANDS CA
92373-1410
US

V. Phone/Fax

Practice location:
  • Phone: 909-335-8894
  • Fax: 909-335-3527
Mailing address:
  • Phone: 909-335-8894
  • Fax: 909-335-3527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number58100
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5675
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: