Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 007430 | CT |
NPI | 1073843785 |
---|---|
Provider Name | Mrs. Jessica Lynn Granger |
First Address | East Haven, CT 06512 |
Second Address | East Haven, CT 06512 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/12/2009 |
Last Update Date | 31/12/2009 |