Healthcare Provider Details

I. General information

NPI: 1649355116
Provider Name (Legal Business Name): JENNIFER DALE LENTZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24276 AIRPORT RD
EAGLE BUTTE SD
57625-8021
US

IV. Provider business mailing address

3330 GILROY DR
INDIAN LAND SC
29707-5533
US

V. Phone/Fax

Practice location:
  • Phone: 605-964-7724
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-00584
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: