Provider Demographics
NPI:1356864516
Name:BEAVER, JESSICA (RDH, BS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BEAVER
Suffix:
Gender:F
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13073 S PLUM GROVE CT
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-5763
Mailing Address - Country:US
Mailing Address - Phone:1801-906-1619
Mailing Address - Fax:
Practice Address - Street 1:13073 S PLUM GROVE CT
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-5763
Practice Address - Country:US
Practice Address - Phone:801-906-1619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9041914-9920124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist