Provider Demographics
NPI:1891179875
Name:KLOENNE, JESSICA MINTIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:MINTIE
Last Name:KLOENNE
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 1:511 SW 10TH AVE STE 804
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2709
Mailing Address - Country:US
Mailing Address - Phone:503-243-2505
Mailing Address - Fax:
Practice Address - Street 1:511 SW 10TH AVE
Practice Address - Street 2:STE 804
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2732
Practice Address - Country:US
Practice Address - Phone:503-243-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist