Basic Information
| Provider Information | |||||||||
| NPI: | 1073032967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRETSCH | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 N HALSTED ST APT 2916 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606611379 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | CAPTAIN JAMES A. LOVELL FEDERAL HEALTH CARE CENTER | ||||||||
| Address2: | 3001 GREEN BAY ROAD | ||||||||
| City: | NORTH CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476881900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2017 | ||||||||
| LastUpdateDate: | 09/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 019.031400 | IL | Y | Dental Providers | Dentist | General Practice |
No ID Information.