Healthcare Provider Details

I. General information

NPI: 1063958502
Provider Name (Legal Business Name): JESSICA HENRICK RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 MEADOW ST NEW HAVEN PUBLIC SCHOOLS
NEW HAVEN CT
06519-1783
US

IV. Provider business mailing address

18 MILLS DR
WEST HAVEN CT
06516-6250
US

V. Phone/Fax

Practice location:
  • Phone: 203-946-4860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7843
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: