Provider Demographics
NPI:1093844573
Name:CORCORAN, JESSICA LILLIE (DDS)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LILLIE
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LILLIE
Other - Last Name:EWOLDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:121 20TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677
Mailing Address - Country:US
Mailing Address - Phone:319-352-5281
Mailing Address - Fax:319-352-0509
Practice Address - Street 1:121 20TH ST NW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677
Practice Address - Country:US
Practice Address - Phone:319-352-5281
Practice Address - Fax:319-352-0509
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1728550Medicaid
IA0728550Medicaid