Provider Demographics
NPI:1699105494
Name:BRICK, JESSICAH MARIE (RDH)
Entity type:Individual
Prefix:
First Name:JESSICAH
Middle Name:MARIE
Last Name:BRICK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 SE 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-4445
Mailing Address - Country:US
Mailing Address - Phone:503-975-5603
Mailing Address - Fax:
Practice Address - Street 1:5025 SE 28TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202
Practice Address - Country:US
Practice Address - Phone:503-975-5603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6522124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist