MEDICARE: JUDITH G. JENKINS DDS

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	1223G0001X	General Practice Dentistry	DD1239	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	DD1239	OTHER	NM	DENTIST LICENSE NUMBER
3	1459740	OTHER	NM	UNITED CONCORDIA INS.
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679641260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDITH G. JENKINS DDS

Provider Business Mailing Address
First Line	:	PO BOX 5395
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87502-5395
Country	:	US
Telephone Number	:	505-984-5048
Fax Number	:	505-983-4751

Provider Business Practice Location Address
First Line	:	1035 ALTO STREET
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87502-5395
Country	:	US
Telephone Number	:	505-984-5048
Fax Number	:	505-983-4751

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

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/09/2007

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