Provider Demographics
NPI:1336695535
Name:MASSOUDA, JACQUELINE D (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:D
Last Name:MASSOUDA
Suffix:
Gender:F
Credentials:DMD
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Other - Credentials:
Mailing Address - Street 1:US ARMY DENTAC: ATTN CREDENTIALS OFFICE
Mailing Address - Street 2:9900 LINCOLN STREET, 2ND FLOOR
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98327
Mailing Address - Country:US
Mailing Address - Phone:253-968-4079
Mailing Address - Fax:253-968-5919
Practice Address - Street 1:JBLM DENTAC
Practice Address - Street 2:9900 LINCOLN SREET, 2ND FLOOR
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:98431
Practice Address - Country:US
Practice Address - Phone:502-759-8448
Practice Address - Fax:253-968-5919
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY97381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice