Provider Demographics
NPI:1528598158
Name:JOSEPH, JESSICA MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:MARIE
Last Name:JOSEPH
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 1:4855 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4686
Mailing Address - Country:US
Mailing Address - Phone:269-375-0800
Mailing Address - Fax:
Practice Address - Street 1:4855 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4686
Practice Address - Country:US
Practice Address - Phone:269-375-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010223111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice