Provider Demographics
NPI:1508260217
Name:JAMROG, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:JAMROG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 VANDENBERG DR
Mailing Address - Street 2:66TH MED SQUADRON, HANSCOM AFB
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01731
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 VANDENBERG DR
Practice Address - Street 2:66TH MED SQUADRON, HANSCOM AFB
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01731-2104
Practice Address - Country:US
Practice Address - Phone:781-225-6324
Practice Address - Fax:781-225-2564
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADH9984124Q00000X
MADH9984OL124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist