Provider Demographics
NPI:1356507925
Name:HETCKO, JESSICA BETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:BETH
Last Name:HETCKO
Suffix:
Gender:F
Credentials:DDS
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Other - Credentials:
Mailing Address - Street 1:921 S. 8TH AVE, STOP 8088
Mailing Address - Street 2:POCATELLO FAMILY DENTISTRY ISU
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-8088
Mailing Address - Country:US
Mailing Address - Phone:208-282-6000
Mailing Address - Fax:208-282-4950
Practice Address - Street 1:465 MEMORIAL DR.
Practice Address - Street 2:POCATELLO FAMILY DENTISTRY ISU
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-8088
Practice Address - Country:US
Practice Address - Phone:208-282-6000
Practice Address - Fax:208-282-4950
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-41801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice