Provider Demographics
NPI:1972369122
Name:ALLRED, JESSICA (RDH, OMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ALLRED
Suffix:
Gender:F
Credentials:RDH, OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 VERLAN WAY
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3197
Mailing Address - Country:US
Mailing Address - Phone:307-887-1326
Mailing Address - Fax:
Practice Address - Street 1:1131 VERLAN WAY
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-3197
Practice Address - Country:US
Practice Address - Phone:307-887-1326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY976124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist