Healthcare Provider Details

I. General information

NPI: 1366746992
Provider Name (Legal Business Name): JESSICA NINA DUSSEAULT RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2010
Last Update Date: 12/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 N 6TH ST
GRAND JUNCTION CO
81501-2001
US

IV. Provider business mailing address

202 WHISPER LN
GRAND JUNCTION CO
81503-6608
US

V. Phone/Fax

Practice location:
  • Phone: 970-255-1782
  • Fax:
Mailing address:
  • Phone: 218-371-9166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number905829
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: