MEDICARE: JESSICA TARA NESSMITH PETERSON RDH, QOM, CERTBBM

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	DH009864	GA

General Provider Information

NPI Number	:	1972200715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA TARA NESSMITH PETERSON RDH, QOM, CERTBBM

Provider Business Mailing Address
First Line	:	5450 COPPER SPRINGS LN
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-5626
Country	:	US
Telephone Number	:	404-441-8917
Fax Number	:

Provider Business Practice Location Address
First Line	:	5450 COPPER SPRINGS LN
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-5626
Country	:	US
Telephone Number	:	404-441-8917
Fax Number	:

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

Provider Enumeration Date	:	02/13/2023
Last Update Date	:	02/13/2023

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