Provider Demographics
NPI:1255666863
Name:MIRRIELEES, JESSICA WALLACE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:WALLACE
Last Name:MIRRIELEES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11080 WAR ADMIRAL DR
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:KY
Mailing Address - Zip Code:41091-7920
Mailing Address - Country:US
Mailing Address - Phone:859-893-5128
Mailing Address - Fax:
Practice Address - Street 1:996 TANNER FORD BLVD
Practice Address - Street 2:
Practice Address - City:HANAHAN
Practice Address - State:SC
Practice Address - Zip Code:29410-4780
Practice Address - Country:US
Practice Address - Phone:843-212-8810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8747122300000X
SC8672122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100176940Medicaid