Provider Demographics
NPI:1083240121
Name:BOYD, JENNIFER LYNN (DENTIAL HYGIENIST)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BOYD
Suffix:
Gender:F
Credentials:DENTIAL HYGIENIST
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:GANCOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1070 OLD NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15333-2114
Mailing Address - Country:US
Mailing Address - Phone:724-632-6801
Mailing Address - Fax:724-632-6312
Practice Address - Street 1:37 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4062
Practice Address - Country:US
Practice Address - Phone:724-223-1067
Practice Address - Fax:724-223-1088
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH013049L124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1002788440027Medicaid