Basic Information
| Provider Information | |||||||||
| NPI: | 1588159263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENDON-VELASQUEZ | ||||||||
| FirstName: | JENNIFFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4027 SOUTHERN OAKS DR UNIT 2 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283140987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014781046 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3817 GRUBER RD | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283108925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103961571 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2018 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 22DI02691100 | NJ | Y | Dental Providers | Dentist | General Practice |
No ID Information.