Provider Demographics
NPI:1003482217
Name:BOURAIN, JOANNA CHRISTINE (DDS)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:CHRISTINE
Last Name:BOURAIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 LONG AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1248
Mailing Address - Country:US
Mailing Address - Phone:805-729-0090
Mailing Address - Fax:
Practice Address - Street 1:1313 PENN AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-3047
Practice Address - Country:US
Practice Address - Phone:805-729-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14545122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist