Provider Demographics
NPI:1912525205
Name:QUACH, JESSICA KHIET
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KHIET
Last Name:QUACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 PINEY FOREST RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2876
Mailing Address - Country:US
Mailing Address - Phone:434-799-8825
Mailing Address - Fax:
Practice Address - Street 1:4940 KINGS MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24078-1812
Practice Address - Country:US
Practice Address - Phone:276-647-1494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401417002122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist