Provider Demographics
NPI:1194848390
Name:TJON SIEUW MORIN, JACQUELINE
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:TJON SIEUW MORIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 SOUTH FACTORY STREET
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-1425
Mailing Address - Country:US
Mailing Address - Phone:207-474-9326
Mailing Address - Fax:
Practice Address - Street 1:28 SOUTH FACTORY STREET
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-1425
Practice Address - Country:US
Practice Address - Phone:207-474-9326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3429122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist