Provider Demographics
NPI:1619535416
Name:SMITH, JESSICA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:294 NELSON RD
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-1942
Mailing Address - Country:US
Mailing Address - Phone:231-843-4255
Mailing Address - Fax:
Practice Address - Street 1:294 NELSON RD
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1942
Practice Address - Country:US
Practice Address - Phone:231-843-4255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901023209122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist