Provider Demographics
NPI:1417179581
Name:EDWARD P. JESSUP, DDS, MSCO, PA
Entity Type:Organization
Organization Name:EDWARD P. JESSUP, DDS, MSCO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:PATTON
Authorized Official - Last Name:JESSUP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-738-4465
Mailing Address - Street 1:4300 LUDGATE STREET
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358
Mailing Address - Country:US
Mailing Address - Phone:910-738-4465
Mailing Address - Fax:
Practice Address - Street 1:4300 LUDGATE STREET
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358
Practice Address - Country:US
Practice Address - Phone:910-738-4465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35681223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty