Provider Demographics
NPI:1538177613
Name:JENOS, GARY GEORGE (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:GEORGE
Last Name:JENOS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23360 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-8265
Mailing Address - Country:US
Mailing Address - Phone:952-985-0916
Mailing Address - Fax:
Practice Address - Street 1:16372 KENRICK AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-3540
Practice Address - Country:US
Practice Address - Phone:952-435-5905
Practice Address - Fax:952-435-6291
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN99621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice