Provider Demographics
NPI:1912102849
Name:JANISSE, JEDIDIAH LG (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEDIDIAH
Middle Name:LG
Last Name:JANISSE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 ROUTE 120
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1430
Mailing Address - Country:US
Mailing Address - Phone:973-296-5022
Mailing Address - Fax:
Practice Address - Street 1:367 ROUTE 120
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1430
Practice Address - Country:US
Practice Address - Phone:973-296-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03932122300000X
VT016-00022471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice