Provider Demographics
NPI:1497062152
Name:REDGATE, JENNA MARIE (DMD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:REDGATE
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 1:3958 LAMONT ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-6177
Mailing Address - Country:US
Mailing Address - Phone:757-619-9422
Mailing Address - Fax:
Practice Address - Street 1:OLD TOWN DENTAL
Practice Address - Street 2:8745 PACIFIC AVE NW SUITE 101
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383
Practice Address - Country:US
Practice Address - Phone:360-692-9437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS105916122300000X
WA616763151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist