Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | R708 | MN |
NPI | 1003300583 |
---|---|
Provider Name | Dr. Jennifer Lynn Bonamici |
First Address | Minneapolis, MN 55415 |
Second Address | Minneapolis, MN 55455-0357 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2018 |
Last Update Date | 19/06/2018 |