Healthcare Provider Details

I. General information

NPI: 1508785270
Provider Name (Legal Business Name): JENNIFER R HAVENS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 N STANFORD LN
LIBERTY LAKE WA
99019-5034
US

IV. Provider business mailing address

15521 N CUSTER CT
MEAD WA
99021-9018
US

V. Phone/Fax

Practice location:
  • Phone: 509-891-5001
  • Fax:
Mailing address:
  • Phone: 509-720-9086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDENT.DE.70147522
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: