Provider Demographics
NPI:1972764926
Name:SMITH, JESSANNA ELIZABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSANNA
Middle Name:ELIZABETH
Last Name:SMITH
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 1:602 FIRST STREET UNIT B
Mailing Address - Street 2:
Mailing Address - City:TYBEE ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31328
Mailing Address - Country:US
Mailing Address - Phone:912-786-9433
Mailing Address - Fax:
Practice Address - Street 1:602 1ST AVE UNIT B
Practice Address - Street 2:
Practice Address - City:TYBEE ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31328-8841
Practice Address - Country:US
Practice Address - Phone:912-786-9433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44931223G0001X
GADN0137911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice