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General NPI Number Information
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NPI Number | 1609144997
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Entity Type | Individual
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Provider Name | JENNI MARIE O'MALLEY D.M.D
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Gender | Female
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Dates
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Enumeration Date | 12/01/2011
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Last Update Date | 10/27/2021
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Provider Practice Location Address
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Address Line | 1105 W STONE DR STE 5
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City | KINGSPORT
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State | TN
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Zip | 37660-2558
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Country | US
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Telephone | 423-224-5697
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Fax |
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Provider Business Mailing Address
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Address Line | 1374 CATTAIL PT
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City | JOHNSON CITY
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State | TN
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Zip | 37601-9404
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Country | US
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Telephone | 407-791-7997
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 27456
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 11246
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License Number State | TN
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 21809
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 27456
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License Number State | TX
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Taxonomy #5
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8896
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License Number State | SC
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