Healthcare Provider Details

I. General information

NPI: 1285075614
Provider Name (Legal Business Name): TODD MICHAEL JENNY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 GROVE ST #300
WORCESTER MA
01605-1270
US

IV. Provider business mailing address

405 GROVE ST #300
WORCESTER MA
01605-1270
US

V. Phone/Fax

Practice location:
  • Phone: 508-753-5444
  • Fax:
Mailing address:
  • Phone: 508-753-5444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN1857286
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: