| NPI | 1649653817 |
|---|---|
| Former Name | JESSICA MARIE BODENBERG |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901021621) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 5315072223) |
| Enumeration Date | 2015-07-06 |
| Last Update Date | 2018-06-26 |