Provider Demographics
NPI:1396029120
Name:ANDERSON, JENNIFER DOLORES (RDH)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:DOLORES
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 BIRDSEYE ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-6827
Mailing Address - Country:US
Mailing Address - Phone:203-385-4090
Mailing Address - Fax:
Practice Address - Street 1:719 BIRDSEYE ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-6827
Practice Address - Country:US
Practice Address - Phone:203-385-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007366124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist