Provider Demographics
NPI:1255648424
Name:KHOURY, JENNA (DMD)
Entity type:Individual
Prefix:DR
First Name:JENNA
Middle Name:
Last Name:KHOURY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4165 EXECUTIVE DR
Mailing Address - Street 2:F201
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1364
Mailing Address - Country:US
Mailing Address - Phone:858-335-5645
Mailing Address - Fax:
Practice Address - Street 1:4165 EXECUTIVE DR
Practice Address - Street 2:F201
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1364
Practice Address - Country:US
Practice Address - Phone:858-335-5645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA609861223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry