Provider Demographics
NPI:1194776583
Name:WITTMAN, JESSICA R (DDS)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:R
Last Name:WITTMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 N KRINGLE PLACE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA CLAUS
Mailing Address - State:IN
Mailing Address - Zip Code:47579
Mailing Address - Country:US
Mailing Address - Phone:812-937-9750
Mailing Address - Fax:812-937-9760
Practice Address - Street 1:1 N KRINGLE PLACE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA CLAUS
Practice Address - State:IN
Practice Address - Zip Code:47579-6153
Practice Address - Country:US
Practice Address - Phone:812-937-9750
Practice Address - Fax:812-937-9760
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120105971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice