Healthcare Provider Details

I. General information

NPI: 1083276174
Provider Name (Legal Business Name): JENNIE ANN BARBER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 W LUMSDEN RD
BRANDON FL
33511-5911
US

IV. Provider business mailing address

10830 JOHANNA AVE
RIVERVIEW FL
33578-4402
US

V. Phone/Fax

Practice location:
  • Phone: 855-939-2667
  • Fax: 855-939-2668
Mailing address:
  • Phone: 813-734-3342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH18429
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: