MEDICARE: JESSICA HENRICK RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	7843	CT

General Provider Information

NPI Number	:	1063958502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA HENRICK RDH

Provider Business Mailing Address
First Line	:	18 MILLS DR
Second Line	:
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-6250
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	54 MEADOW ST
Second Line	:	NEW HAVEN PUBLIC SCHOOLS
City	:	NEW HAVEN
State	:	CT
Zip	:	06519-1783
Country	:	US
Telephone Number	:	203-946-4860
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2017
Last Update Date	:	01/09/2017

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