Provider Demographics
NPI:1073981700
Name:MEPHAM, JESSICA LAUREN (DDS)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LAUREN
Last Name:MEPHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:LAUREN
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3715 WESTON AVE
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-5243
Mailing Address - Country:US
Mailing Address - Phone:517-359-7898
Mailing Address - Fax:
Practice Address - Street 1:3715 WESTON AVE
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-5243
Practice Address - Country:US
Practice Address - Phone:517-359-7898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10130122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist