Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D14545 | MN |
NPI | 1003482217 |
---|---|
Provider Name | Joanna Christine Bourain |
First Address | Saint Paul, MN 55114-1248 |
Second Address | Minneapolis, MN 55411-3047 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/05/2021 |
Last Update Date | 28/05/2021 |