Provider Demographics
NPI:1336669977
Name:ISABELLE, JACQUELINE (DDS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ISABELLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 BERMUDA DUNES CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3114
Mailing Address - Country:US
Mailing Address - Phone:240-535-3059
Mailing Address - Fax:
Practice Address - Street 1:8363 CHERRY LN
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707
Practice Address - Country:US
Practice Address - Phone:301-245-6711
Practice Address - Fax:301-490-0402
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-25
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD166681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program