Basic Information
| Provider Information | |||||||||
| NPI: | 1922448117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOMER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3004 TWISTED OAK DR | ||||||||
| Address2: | |||||||||
| City: | EGLIN AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325421441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622275244 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 307 BOATNER RD STE 114 | ||||||||
| Address2: | |||||||||
| City: | EGLIN AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325421302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508838600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2013 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 7080-15 | WI | N | Dental Providers | Dentist | 1223G0001X | 7080-15 | WI | N | Dental Providers | Dentist | General Practice | 1223G0001X | DN015596 | GA | N | Dental Providers | Dentist | General Practice | 1223G0001X | DN25620 | FL | Y | Dental Providers | Dentist | General Practice |
No ID Information.