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General NPI Number Information
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NPI Number | 1851650287
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Entity Type | Individual
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Provider Name | JESSICA MARIE SOUTHEARD R.D.H
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Gender | Female
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Dates
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Enumeration Date | 05/04/2012
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Last Update Date | 07/22/2013
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Provider Practice Location Address
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Address Line | 10205 N RIVA RIDGE LOOP
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City | FORT DRUM
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State | NY
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Zip | 13602-5457
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Country | US
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Telephone | 315-772-8843
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Fax |
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Provider Business Mailing Address
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Address Line | 10205 N RIVA RIDGE LOOP
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City | FORT DRUM
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State | NY
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Zip | 13602-5457
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Country | US
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Telephone | 315-772-8843
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 7426 C1
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License Number State | AL
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