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General NPI Number Information
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NPI Number | 1356330344
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Entity Type | Individual
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Provider Name | JENNIFER A DIEDERICH DMD
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Gender | Female
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Dates
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Enumeration Date | 10/21/2005
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Last Update Date | 09/30/2015
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Provider Practice Location Address
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Address Line | 222 MAIN ST PMB 251
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City | FARMINGTON
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State | CT
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Zip | 06032-3623
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Country | US
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Telephone | 860-751-9209
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Fax | 860-693-6309
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Provider Business Mailing Address
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Address Line | 222 MAIN ST #251
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City | FARMINGTON
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State | CT
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Zip | 06032-3623
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Country | US
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Telephone | 860-470-3660
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Fax | 860-404-5642
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 007122
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License Number State | CT
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