Healthcare Provider Details

I. General information

NPI: 1851650287
Provider Name (Legal Business Name): JESSICA MARIE SOUTHEARD R.D.H
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10205 N RIVA RIDGE LOOP
FORT DRUM NY
13602-5457
US

IV. Provider business mailing address

10205 N RIVA RIDGE LOOP
FORT DRUM NY
13602-5457
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-8843
  • Fax:
Mailing address:
  • Phone: 315-772-8843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7426 C1
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: