Provider Demographics
NPI:1285718304
Name:FONKERT, JODI MICHELLE (DDS)
Entity type:Individual
Prefix:DR
First Name:JODI
Middle Name:MICHELLE
Last Name:FONKERT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 SOUTH FIRST STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201
Mailing Address - Country:US
Mailing Address - Phone:320-235-2780
Mailing Address - Fax:320-235-8838
Practice Address - Street 1:1101 SOUTH FIRST STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201
Practice Address - Country:US
Practice Address - Phone:320-235-2780
Practice Address - Fax:320-235-8838
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10807122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN30751330Medicaid