=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700989993
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRETCHEN MAROUL JETTON DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2015 E BRAODWAY STE B
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-485-7012
-----------------------------------------------------
Fax | 281-485-3376
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 374
-----------------------------------------------------
City | GUY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-858-0906
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 21035
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------