Provider Demographics
NPI:1356330344
Name:DIEDERICH, JENNIFER A (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:A
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:DIEDERICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:222 MAIN ST
Mailing Address - Street 2:#251
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-3623
Mailing Address - Country:US
Mailing Address - Phone:860-470-3660
Mailing Address - Fax:860-404-5642
Practice Address - Street 1:222 MAIN ST
Practice Address - Street 2:PMB 251
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-3623
Practice Address - Country:US
Practice Address - Phone:860-751-9209
Practice Address - Fax:860-693-6309
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0071221223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice