Provider Demographics
NPI:1306238852
Name:CORRIEL, JESSICA K (DMD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:K
Last Name:CORRIEL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:K
Other - Last Name:KENEMUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:4702 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1823
Mailing Address - Country:US
Mailing Address - Phone:475-422-5193
Mailing Address - Fax:
Practice Address - Street 1:4702 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1823
Practice Address - Country:US
Practice Address - Phone:475-422-5193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT117651223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry