Provider Demographics
NPI:1629066634
Name:BREWSTER, JESSICA M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:M
Last Name:BREWSTER
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 1:724 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1363
Mailing Address - Country:US
Mailing Address - Phone:505-982-5596
Mailing Address - Fax:
Practice Address - Street 1:1035 ALTO STREET
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87502-2406
Practice Address - Country:US
Practice Address - Phone:505-984-5048
Practice Address - Fax:505-983-4751
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1846122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM87685Medicaid