Provider Demographics
NPI:1164653473
Name:WOLLER, JESSICA L (DMD, MSD, CO)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:L
Last Name:WOLLER
Suffix:
Gender:F
Credentials:DMD, MSD, CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 LATHROP ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5937
Mailing Address - Country:US
Mailing Address - Phone:907-452-2939
Mailing Address - Fax:907-451-7330
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE 102
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-452-2939
Practice Address - Fax:907-451-7330
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1249122300000X
AK1621223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist