MEDICARE: DR. JESSICA JEAN SNELLER D.D.S.

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	2901021629	MI
2	122300000X	Dentist	2901021629	MI

General Provider Information

NPI Number	:	1245613934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA JEAN SNELLER D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 36
Second Line	:
City	:	NEW ERA
State	:	MI
Zip	:	49446-0036
Country	:	US
Telephone Number	:	231-861-5905
Fax Number	:

Provider Business Practice Location Address
First Line	:	4711 1ST ST
Second Line	:
City	:	NEW ERA
State	:	MI
Zip	:	49446-5100
Country	:	US
Telephone Number	:	231-861-5905
Fax Number	:

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

Provider Enumeration Date	:	06/30/2015
Last Update Date	:	06/30/2015

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