Provider Demographics
NPI:1396811451
Name:SMITH, JACQUELINE BROWN (DDS)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:BROWN
Last Name:SMITH
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 1:512 LEARY CT
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-6687
Mailing Address - Country:US
Mailing Address - Phone:757-558-2274
Mailing Address - Fax:
Practice Address - Street 1:621 LYNNHAVEN PKWY STE 255
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7383
Practice Address - Country:US
Practice Address - Phone:757-738-2981
Practice Address - Fax:757-424-2226
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73301223G0001X
VA0401411605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899018VMedicaid