Provider Demographics
NPI:1922867407
Name:GRISALES, JENIFER ANDREA
Entity type:Individual
Prefix:MISS
First Name:JENIFER
Middle Name:ANDREA
Last Name:GRISALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 ADAMS ST APT 204
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-6453
Mailing Address - Country:US
Mailing Address - Phone:786-915-9872
Mailing Address - Fax:
Practice Address - Street 1:488 ESSEX ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1242
Practice Address - Country:US
Practice Address - Phone:978-975-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN100008801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice