Healthcare Provider Details

I. General information

NPI: 1336695535
Provider Name (Legal Business Name): JACQUELINE D MASSOUDA D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JBLM DENTAC 9900 LINCOLN SREET, 2ND FLOOR
APO AA
98431
US

IV. Provider business mailing address

US ARMY DENTAC: ATTN CREDENTIALS OFFICE 9900 LINCOLN STREET, 2ND FLOOR
TACOMA WA
98327
US

V. Phone/Fax

Practice location:
  • Phone: 502-759-8448
  • Fax: 253-968-5919
Mailing address:
  • Phone: 253-968-4079
  • Fax: 253-968-5919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9738
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: