Provider Demographics
NPI:1174839948
Name:FOSS, JEANNI R (DDS)
Entity Type:Individual
Prefix:
First Name:JEANNI
Middle Name:R
Last Name:FOSS
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 1:15616 EDGEWOOD DR STE 110
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4492
Mailing Address - Country:US
Mailing Address - Phone:218-828-0565
Mailing Address - Fax:
Practice Address - Street 1:15616 EDGEWOOD DR STE 110
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56401-4492
Practice Address - Country:US
Practice Address - Phone:218-828-0565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice