Provider Demographics
NPI:1407263247
Name:WATERBURY, JESSICA JILL (DDS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JILL
Last Name:WATERBURY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1926 COLLEGEVIEW RD E
Mailing Address - Street 2:HC 116
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-8201
Mailing Address - Country:US
Mailing Address - Phone:507-258-4046
Mailing Address - Fax:
Practice Address - Street 1:1926 COLLEGEVIEW RD E
Practice Address - Street 2:HC 116
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-8201
Practice Address - Country:US
Practice Address - Phone:507-258-4046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13437122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist