Provider Demographics
NPI:1174981815
Name:VENTURIN, JAQUELINE (DDS)
Entity type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:
Last Name:VENTURIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 UNION AVE FL 5
Mailing Address - Street 2:ROOM N517
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3513
Mailing Address - Country:US
Mailing Address - Phone:901-448-2242
Mailing Address - Fax:
Practice Address - Street 1:875 UNION AVE FL 5
Practice Address - Street 2:ROOM N517
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3513
Practice Address - Country:US
Practice Address - Phone:901-448-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60315764390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program