Healthcare Provider Details

I. General information

NPI: 1699032169
Provider Name (Legal Business Name): ROBBY JENNINGS DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5011 TROUP HWY # 700
TYLER TX
75707-1917
US

IV. Provider business mailing address

5011 TROUP HWY # 700
TYLER TX
75707-1917
US

V. Phone/Fax

Practice location:
  • Phone: 903-581-5500
  • Fax: 903-581-5510
Mailing address:
  • Phone: 903-581-5500
  • Fax: 903-581-5510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number18962
License Number StateTX

VIII. Authorized Official

Name: EMILY BRASHER
Title or Position: OFFICE MANAGER
Credential:
Phone: 903-581-5500