Basic Information
| Provider Information | |||||||||
| NPI: | 1083240121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYD | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DENTIAL HYGIENIST | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GANCOS | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1070 OLD NATIONAL PIKE | ||||||||
| Address2: | |||||||||
| City: | FREDERICKTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153332114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246326801 | ||||||||
| FaxNumber: | 7246326312 | ||||||||
| Practice Location | |||||||||
| Address1: | 37 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153014062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242231067 | ||||||||
| FaxNumber: | 7242231088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2020 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH013049L | PA | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 1002788440027 | 05 | PA | MEDICAID |