Provider Demographics
NPI:1639430440
Name:ELLIS, JESSICA CHRISTINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:CHRISTINE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:CHRISTINE
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1221 NE BEACON AVE
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-8454
Mailing Address - Country:US
Mailing Address - Phone:816-521-1312
Mailing Address - Fax:
Practice Address - Street 1:12400 E US HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-5929
Practice Address - Country:US
Practice Address - Phone:816-897-5850
Practice Address - Fax:816-897-5851
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160016931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice