Provider Demographics
NPI:1538390695
Name:FULLER, JESSICA KAY (DDS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:KAY
Last Name:FULLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:KAY
Other - Last Name:BOEHRS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2727 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-4844
Mailing Address - Country:US
Mailing Address - Phone:319-363-3575
Mailing Address - Fax:
Practice Address - Street 1:2727 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-4844
Practice Address - Country:US
Practice Address - Phone:319-363-3575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-08981122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist