Provider Demographics
NPI:1013592831
Name:SOARES, JESSICA OLIVEIRA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:OLIVEIRA
Last Name:SOARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8863 CAMERON CREST DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-4732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8863 CAMERON CREST DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4732
Practice Address - Country:US
Practice Address - Phone:813-295-5210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28008122300000X
FLDRPM2268390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program