Provider Demographics
NPI:1013641927
Name:CASSIO, JENNIFER (IPDH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CASSIO
Suffix:
Gender:F
Credentials:IPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 OLD PORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:NORTH WATERBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04061-4903
Mailing Address - Country:US
Mailing Address - Phone:207-206-2125
Mailing Address - Fax:
Practice Address - Street 1:171 OLD PORTLAND RD
Practice Address - Street 2:
Practice Address - City:NORTH WATERBORO
Practice Address - State:ME
Practice Address - Zip Code:04061-4903
Practice Address - Country:US
Practice Address - Phone:207-206-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERDH2718124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist