Provider Demographics
NPI:1427537513
Name:THAYER, JESSICA (DMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:THAYER
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 1:1090 E WELDON AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5046
Mailing Address - Country:US
Mailing Address - Phone:928-301-4442
Mailing Address - Fax:505-899-4804
Practice Address - Street 1:1048 UNION ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3016
Practice Address - Country:US
Practice Address - Phone:207-404-8200
Practice Address - Fax:207-947-0435
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0099281223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEDEN4740OtherSTATE LICENSE