Provider Demographics
NPI:1700222569
Name:WEDEMEYER, JACLYN D (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:D
Last Name:WEDEMEYER
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 1:7107 NORTHAMPTON WAY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-7624
Mailing Address - Country:US
Mailing Address - Phone:713-823-7005
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST
Practice Address - Street 2:SUITE 310
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3000
Practice Address - Country:US
Practice Address - Phone:713-823-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28718122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist