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General NPI Number Information
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NPI Number | 1083977672
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Entity Type | Individual
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Provider Name | JESSICA LEIGH BOGUCKI DMD
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Gender | Female
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Dates
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Enumeration Date | 06/19/2012
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Last Update Date | 11/26/2024
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Provider Practice Location Address
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Address Line | 921 STATE ST
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City | NEW HAVEN
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State | CT
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Zip | 06511-3926
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Country | US
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Telephone | 203-865-2245
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Fax |
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Provider Business Mailing Address
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Address Line | 830 CHALKSTONE AVE
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City | PROVIDENCE
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State | RI
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Zip | 02908-4734
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Country | US
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Telephone | 860-391-2445
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 010957
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License Number State | CT
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