Healthcare Provider Details

I. General information

NPI: 1427537513
Provider Name (Legal Business Name): JESSICA THAYER DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1048 UNION ST
BANGOR ME
04401-3016
US

IV. Provider business mailing address

1090 E WELDON AVE
PHOENIX AZ
85014-5046
US

V. Phone/Fax

Practice location:
  • Phone: 207-404-8200
  • Fax: 207-947-0435
Mailing address:
  • Phone: 928-301-4442
  • Fax: 505-899-4804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD009928
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: