1497273221 NPI number — DR. JESSICA ETCHELL DMD

Table of content: DR. JESSICA ETCHELL DMD (NPI 1497273221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497273221 NPI number — DR. JESSICA ETCHELL DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETCHELL
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497273221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1213 MUSCATO CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89144-1122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-326-0690
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 E DEER SPRINGS WAY STE 180
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89086-1514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-399-3800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  6947 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)