Provider Demographics
NPI:1912383217
Name:BRUNWORTH, JESSICA ALANNA SCULLY (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ALANNA SCULLY
Last Name:BRUNWORTH
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:SCULLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:1351 JEFFERSON ST STE 202
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-6449
Mailing Address - Country:US
Mailing Address - Phone:314-884-0478
Mailing Address - Fax:
Practice Address - Street 1:1351 JEFFERSON ST STE 202
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-6449
Practice Address - Country:US
Practice Address - Phone:314-884-0478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015023903122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist