Healthcare Provider Details

I. General information

NPI: 1174981815
Provider Name (Legal Business Name): JAQUELINE VENTURIN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 UNION AVE FL 5 ROOM N517
MEMPHIS TN
38103-3513
US

IV. Provider business mailing address

875 UNION AVE FL 5 ROOM N517
MEMPHIS TN
38103-3513
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-2242
  • Fax:
Mailing address:
  • Phone: 901-448-2242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDE60315764
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: