Healthcare Provider Details

I. General information

NPI: 1376305920
Provider Name (Legal Business Name): JENNIFER NICOLE CHIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4422 3RD AVE
BRONX NY
10457-2545
US

IV. Provider business mailing address

8 JOHN ST
SOUTHPORT CT
06890-1437
US

V. Phone/Fax

Practice location:
  • Phone: 718-960-9000
  • Fax:
Mailing address:
  • Phone: 203-319-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1376305920
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: