Provider Demographics
NPI:1619060795
Name:DAVIS, JESSICA L (DDS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:DAVIS
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:PO BOX 510
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971-0510
Mailing Address - Country:US
Mailing Address - Phone:920-748-6122
Mailing Address - Fax:
Practice Address - Street 1:644 W OSHKOSH ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-1001
Practice Address - Country:US
Practice Address - Phone:920-748-6122
Practice Address - Fax:920-748-6070
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5244-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33761900Medicaid