Provider Demographics
NPI:1063599066
Name:DUQUETTE, JESSE WILLIAM
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:WILLIAM
Last Name:DUQUETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 MICHIGAN RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-2721
Mailing Address - Country:US
Mailing Address - Phone:812-273-6744
Mailing Address - Fax:
Practice Address - Street 1:1739 MICHIGAN RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-2721
Practice Address - Country:US
Practice Address - Phone:812-273-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010146A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist