Provider Demographics
NPI:1942748801
Name:BROTZ, JENNIFER (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BROTZ
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 1:22 KENT TOWN MARKET
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21619-2632
Mailing Address - Country:US
Mailing Address - Phone:410-643-5500
Mailing Address - Fax:
Practice Address - Street 1:22 KENT TOWN MARKET
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:MD
Practice Address - Zip Code:21619-2632
Practice Address - Country:US
Practice Address - Phone:410-643-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD163161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program