Provider Demographics
NPI:1710471941
Name:WHARTON, JESSICA BROOKE (DDS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BROOKE
Last Name:WHARTON
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 1:581 UNIVERSITY BLVD #400
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665
Mailing Address - Country:US
Mailing Address - Phone:512-244-3333
Mailing Address - Fax:512-341-0631
Practice Address - Street 1:581 UNIVERSITY BLVD #400
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665
Practice Address - Country:US
Practice Address - Phone:512-244-3333
Practice Address - Fax:512-341-0631
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041745122300000X
TX359461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX454338101Medicaid