Provider Demographics
NPI:1952643025
Name:JESSUP, EDWARD P (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:P
Last Name:JESSUP
Suffix:
Gender:M
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:PO BOX 1545
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359-1545
Mailing Address - Country:US
Mailing Address - Phone:910-738-4465
Mailing Address - Fax:910-738-7802
Practice Address - Street 1:4300 LUDGATE ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2461
Practice Address - Country:US
Practice Address - Phone:910-738-4465
Practice Address - Fax:910-738-7802
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35681223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics