Provider Demographics
NPI:1235860545
Name:FONGEMIE, JENNA MAE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:MAE
Last Name:FONGEMIE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 WESTERN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-7269
Mailing Address - Country:US
Mailing Address - Phone:207-622-1488
Mailing Address - Fax:
Practice Address - Street 1:94 WESTERN AVE STE 1
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-7269
Practice Address - Country:US
Practice Address - Phone:207-622-1488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-19
Last Update Date:2022-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN49781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice