Provider Demographics
NPI:1649526468
Name:NILES, JENNIFER (DMD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:NILES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 KELLOGG RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX JCT
Mailing Address - State:VT
Mailing Address - Zip Code:05452-2815
Mailing Address - Country:US
Mailing Address - Phone:802-879-5151
Mailing Address - Fax:
Practice Address - Street 1:4 KELLOGG RD
Practice Address - Street 2:
Practice Address - City:ESSEX JCT
Practice Address - State:VT
Practice Address - Zip Code:05452-2815
Practice Address - Country:US
Practice Address - Phone:802-879-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016.0088863122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist