Provider Demographics
NPI:1538392162
Name:SUGAJARA MITSUZUKA, JESSICA PAOLA (DDS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:PAOLA
Last Name:SUGAJARA MITSUZUKA
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 1:385 GARRISONVILLE RD SIUTE 108
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554
Mailing Address - Country:US
Mailing Address - Phone:540-657-7645
Mailing Address - Fax:540-657-1009
Practice Address - Street 1:385 GARRISONVILLE RD SUITE 108
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554
Practice Address - Country:US
Practice Address - Phone:540-657-7645
Practice Address - Fax:540-657-1009
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413419122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1538392162Medicaid