Healthcare Provider Details

I. General information

NPI: 1801977483
Provider Name (Legal Business Name): JENNIFER VIENNEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 N ROCKY POINT DR SUITE 1000 -CREDENTIALING
TAMPA FL
33607-1421
US

IV. Provider business mailing address

2502 N ROCKY POINT DR SUITE 1000 -CREDENTIALING
TAMPA FL
33607-1421
US

V. Phone/Fax

Practice location:
  • Phone: 813-288-1999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN16871
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: