Provider Demographics
NPI:1144588070
Name:UDE, JENNA BERGIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:BERGIN
Last Name:UDE
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 1:11700 WOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2386
Mailing Address - Country:US
Mailing Address - Phone:218-330-7008
Mailing Address - Fax:
Practice Address - Street 1:15167 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-6946
Practice Address - Country:US
Practice Address - Phone:218-828-0565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-28
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND130671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice