Provider Demographics
NPI:1982237533
Name:ANDERSON, JESSICA R (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 WILLIAMS ST UNIT 111
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6192
Mailing Address - Country:US
Mailing Address - Phone:479-571-0216
Mailing Address - Fax:
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0150
Practice Address - Country:US
Practice Address - Phone:706-721-9744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-21
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN016101122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist