MEDICARE: MRS. JENNIFER M KILEY RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	16598	TX

General Provider Information

NPI Number	:	1538518642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER M KILEY RDH

Provider Business Mailing Address
First Line	:	2212 INFANTRY POST RD
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-1306
Country	:	US
Telephone Number	:	206-280-1142
Fax Number	:

Provider Business Practice Location Address
First Line	:	3145 GARDEN AVE
Second Line	:	STE 1278
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-7718
Country	:	US
Telephone Number	:	210-808-3735
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2016
Last Update Date	:	06/09/2016

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