Provider Demographics
NPI:1508241746
Name:SERVAIS, JACQUELINE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:SERVAIS
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 1:7905 MALCOLM RD
Mailing Address - Street 2:STE 104
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-1734
Mailing Address - Country:US
Mailing Address - Phone:301-868-7228
Mailing Address - Fax:
Practice Address - Street 1:7905 MALCOLM RD
Practice Address - Street 2:STE 104
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-1734
Practice Address - Country:US
Practice Address - Phone:301-868-7228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD158961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice