Healthcare Provider Details

I. General information

NPI: 1629066634
Provider Name (Legal Business Name): JESSICA M BREWSTER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 ALTO STREET
SANTA FE NM
87502-2406
US

IV. Provider business mailing address

724 JUNIPER DR
SANTA FE NM
87501-1363
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-5048
  • Fax: 505-983-4751
Mailing address:
  • Phone: 505-982-5596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1846
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: