Basic Information
| Provider Information | |||||||||
| NPI: | 1629377676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZICKERT | ||||||||
| OtherFirstName: | MARIA | ||||||||
| OtherMiddleName: | CHRISTINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RDH | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 888 WORCESTER ST | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | WELLESLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024823744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179646681 | ||||||||
| FaxNumber: | 3396862561 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S EXECUTIVE DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530054216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889646681 | ||||||||
| FaxNumber: | 8886620859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2011 | ||||||||
| LastUpdateDate: | 09/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 10947-016 | WI | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 1629377676 | 05 | WI | MEDICAID |