Provider Demographics
NPI:1326486499
Name:AULTMAN, JEANNA LYN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEANNA
Middle Name:LYN
Last Name:AULTMAN
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:PO BOX 469
Mailing Address - Street 2:
Mailing Address - City:SUMRALL
Mailing Address - State:MS
Mailing Address - Zip Code:39482
Mailing Address - Country:US
Mailing Address - Phone:601-758-0150
Mailing Address - Fax:601-758-0149
Practice Address - Street 1:4556 HIGHWAY 589
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482-3979
Practice Address - Country:US
Practice Address - Phone:601-758-0150
Practice Address - Fax:601-758-0149
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3690-13122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist