Provider Demographics
NPI:1528430477
Name:VIDETICH, JESSICA LEE (RDH)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LEE
Last Name:VIDETICH
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 1:2700 BAKER ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON HTS
Mailing Address - State:MI
Mailing Address - Zip Code:49444-2157
Mailing Address - Country:US
Mailing Address - Phone:231-737-8603
Mailing Address - Fax:
Practice Address - Street 1:2700 BAKER ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON HTS
Practice Address - State:MI
Practice Address - Zip Code:49444-2157
Practice Address - Country:US
Practice Address - Phone:231-737-8603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL485276124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist