Provider Demographics
NPI:1104207067
Name:SANBORN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SANBORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8078 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-2450
Mailing Address - Country:US
Mailing Address - Phone:515-276-7800
Mailing Address - Fax:
Practice Address - Street 1:8078 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-2450
Practice Address - Country:US
Practice Address - Phone:515-276-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE72311223G0001X
IADDS-098251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice