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General NPI Number Information
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NPI Number | 1912102849
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Entity Type | Individual
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Provider Name | JEDIDIAH L.G. JANISSE DMD
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Gender | Male
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Dates
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Enumeration Date | 06/20/2007
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Last Update Date | 03/09/2015
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Provider Practice Location Address
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Address Line | 367 ROUTE 120
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City | LEBANON
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State | NH
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Zip | 03766-1430
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Country | US
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Telephone | 973-296-5022
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Fax |
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Provider Business Mailing Address
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Address Line | 367 ROUTE 120
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City | LEBANON
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State | NH
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Zip | 03766-1430
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Country | US
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Telephone | 973-296-5022
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Fax |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 03932
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License Number State | NH
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 016-0002247
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License Number State | VT
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