Provider Demographics
NPI:1902115892
Name:SMITH, JESSICA C (DDS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:C
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 1:886 BOYSEN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1311
Mailing Address - Country:US
Mailing Address - Phone:805-471-1211
Mailing Address - Fax:
Practice Address - Street 1:886 BOYSEN AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405
Practice Address - Country:US
Practice Address - Phone:805-543-4700
Practice Address - Fax:805-543-7231
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1362122300000X
CA58962122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist