Provider Demographics
NPI:1982988754
Name:CONGDON, JILL A (RDH)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:CONGDON
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 1:27 POTTER VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01507-6723
Mailing Address - Country:US
Mailing Address - Phone:617-571-1697
Mailing Address - Fax:
Practice Address - Street 1:103 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:MA
Practice Address - Zip Code:02631-2429
Practice Address - Country:US
Practice Address - Phone:617-571-1697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11157124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist