MEDICARE: MRS. JESSICA MARIE SOUTHEARD R.D.H

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	124Q00000X	Dental Hygienist	7426 C1	AL

General Provider Information

NPI Number	:	1851650287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA MARIE SOUTHEARD R.D.H

Provider Business Mailing Address
First Line	:	10205 N RIVA RIDGE LOOP
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13602-5457
Country	:	US
Telephone Number	:	315-772-8843
Fax Number	:

Provider Business Practice Location Address
First Line	:	10205 N RIVA RIDGE LOOP
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13602-5457
Country	:	US
Telephone Number	:	315-772-8843
Fax Number	:

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

Provider Enumeration Date	:	05/04/2012
Last Update Date	:	07/22/2013

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Directions to “ MRS. JESSICA MARIE SOUTHEARD R.D.H” Practice Location

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