Healthcare Provider Details

I. General information

NPI: 1013641927
Provider Name (Legal Business Name): JENNIFER CASSIO IPDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 OLD PORTLAND RD
NORTH WATERBORO ME
04061-4903
US

IV. Provider business mailing address

171 OLD PORTLAND RD
NORTH WATERBORO ME
04061-4903
US

V. Phone/Fax

Practice location:
  • Phone: 207-206-2125
  • Fax:
Mailing address:
  • Phone: 207-206-2125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH2718
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: