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NPI Code Detail

MEDICARE: DR. JESSICA WALLACE MIRRIELEES DMD

MEDICARE: DR. JESSICA WALLACE MIRRIELEES DMD
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
1122300000XDentist8747KY
2122300000XDentist8672SC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1255666863
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JESSICA WALLACE MIRRIELEES DMD
Provider Business Mailing Address
First Line : 11080 WAR ADMIRAL DR
Second Line :
City : UNION
State : KY
Zip : 41091-7920
Country : US
Telephone Number : 859-893-5128
Fax Number :
Provider Business Practice Location Address
First Line : 996 TANNER FORD BLVD
Second Line :
City : HANAHAN
State : SC
Zip : 29410-4780
Country : US
Telephone Number : 843-212-8810
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/15/2009
Last Update Date : 05/27/2021

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