Provider Demographics
NPI:1316041437
Name:ROBERTSON, JESSICA LORRAINE (DMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LORRAINE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1773 W SEQUOIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-213-5559
Mailing Address - Fax:
Practice Address - Street 1:1024 N SAN FRANCISCO
Practice Address - Street 2:SUITE 101
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-779-0385
Practice Address - Fax:928-779-6487
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD68141223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry