Healthcare Provider Details

I. General information

NPI: 1982988754
Provider Name (Legal Business Name): JILL A CONGDON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 LAKE SHORE DR
BREWSTER MA
02631-2429
US

IV. Provider business mailing address

27 POTTER VILLAGE RD
CHARLTON MA
01507-6723
US

V. Phone/Fax

Practice location:
  • Phone: 617-571-1697
  • Fax:
Mailing address:
  • Phone: 617-571-1697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number11157
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: