Healthcare Provider Details

I. General information

NPI: 1205330420
Provider Name (Legal Business Name): JENDY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 W EVEREST LN STE 125
MERIDIAN ID
83646-6113
US

IV. Provider business mailing address

3235 N TOWERBRIDGE WAY STE 200
MERIDIAN ID
83646-5721
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-6343
  • Fax:
Mailing address:
  • Phone: 208-888-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD3868-PD
License Number StateID

VIII. Authorized Official

Name: DR. JOEL E WHITT
Title or Position: PRESIDENT
Credential: DMD
Phone: 208-631-2212