Provider Demographics
NPI:1083977672
Name:BOGUCKI, JESSICA LEIGH (DMD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LEIGH
Last Name:BOGUCKI
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 1:830 CHALKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4734
Mailing Address - Country:US
Mailing Address - Phone:860-391-2445
Mailing Address - Fax:
Practice Address - Street 1:921 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3926
Practice Address - Country:US
Practice Address - Phone:203-865-2245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010957122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist