Provider Demographics
NPI:1902286842
Name:PERRAULT, JENNIFER GLADYS JOHNSON (DDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GLADYS JOHNSON
Last Name:PERRAULT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:GLADYS
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:17854 457TH AVE
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267
Mailing Address - Country:US
Mailing Address - Phone:218-204-0259
Mailing Address - Fax:
Practice Address - Street 1:201 E 6TH ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-1212
Practice Address - Country:US
Practice Address - Phone:320-589-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist