MEDICARE: JENNIE M VAN DMD

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	DN17997	FL

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

General Provider Information

NPI Number	:	1831399344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIE M VAN DMD

Provider Business Mailing Address
First Line	:	3804 E COLONIAL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-5208
Country	:	US
Telephone Number	:	407-898-3800
Fax Number	:	407-895-0503

Provider Business Practice Location Address
First Line	:	3804 E COLONIAL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-5208
Country	:	US
Telephone Number	:	407-898-3800
Fax Number	:	407-895-0503

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

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	04/24/2023

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Directions to “ JENNIE M VAN DMD” Practice Location

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