MEDICARE: DR. JESSICA MERCEDES MINTON 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	122300000X	Dentist	9022	TN

General Provider Information

NPI Number	:	1629207428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA MERCEDES MINTON D.D.S.

Provider Business Mailing Address
First Line	:	210 CEDAR FORK RD
Second Line	:
City	:	TAZEWELL
State	:	TN
Zip	:	37879-3201
Country	:	US
Telephone Number	:	423-626-7070
Fax Number	:	423-626-7060

Provider Business Practice Location Address
First Line	:	210 CEDAR FORK RD
Second Line	:
City	:	TAZEWELL
State	:	TN
Zip	:	37879-3201
Country	:	US
Telephone Number	:	423-626-7070
Fax Number	:	423-626-7060

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

Provider Enumeration Date	:	07/14/2009
Last Update Date	:	01/10/2011

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