Basic Information
Provider Information
NPI: 1033557293
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: EZEH
FirstName: JENNIFER
MiddleName: C
NamePrefix: DR.
NameSuffix:  
Credential: D.D.S
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 1908
Address2:  
City: GREENVILLE
State: TX
PostalCode: 754031908
CountryCode: US
TelephoneNumber: 9034543025
FaxNumber: 9034501408
Practice Location
Address1: 3600 CADDO ST
Address2:  
City: GREENVILLE
State: TX
PostalCode: 754014511
CountryCode: US
TelephoneNumber: 9034546965
FaxNumber: 9034547981
Other Information
ProviderEnumerationDate: 06/10/2013
LastUpdateDate: 03/03/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X28921TXY Dental ProvidersDentistGeneral Practice

No ID Information.


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