Provider Demographics
NPI:1184813164
Name:JESSUP, RONALD DEAN (DMD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:DEAN
Last Name:JESSUP
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:RONALD
Other - Middle Name:DEAN
Other - Last Name:JESSUP, D.M.D., PC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:14245 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-4317
Mailing Address - Country:US
Mailing Address - Phone:276-628-8164
Mailing Address - Fax:276-644-3145
Practice Address - Street 1:14245 LEE HWY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-4317
Practice Address - Country:US
Practice Address - Phone:276-628-8164
Practice Address - Fax:276-644-3145
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008645122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007800568Medicaid
VA00701762OtherUNITED CONCORDIA
VA041008645AOtherDELTA DENTAL