MEDICARE: DR. JESSICA MARIE JOSEPH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2901022311	MI

General Provider Information

NPI Number	:	1528598158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA MARIE JOSEPH DDS

Provider Business Mailing Address
First Line	:	4855 W CENTRE AVE
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-4686
Country	:	US
Telephone Number	:	269-375-0800
Fax Number	:

Provider Business Practice Location Address
First Line	:	4855 W CENTRE AVE
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49024-4686
Country	:	US
Telephone Number	:	269-375-0800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2017
Last Update Date	:	02/10/2021

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