Provider Demographics
NPI:1528187234
Name:BRODEUR, JESSICA (RDH)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:BRODEUR
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 COTTAGE ST
Mailing Address - Street 2:#5
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-3675
Mailing Address - Country:US
Mailing Address - Phone:774-451-3521
Mailing Address - Fax:
Practice Address - Street 1:15 WARREN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-4015
Practice Address - Country:US
Practice Address - Phone:781-963-3800
Practice Address - Fax:781-963-6906
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11958124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist