Provider Demographics
NPI:1730444035
Name:WOODRUFF, JILLIAN SKEETERS
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:SKEETERS
Last Name:WOODRUFF
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 1:982 LEE ANN DR NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2957
Mailing Address - Country:US
Mailing Address - Phone:704-787-9355
Mailing Address - Fax:704-787-9554
Practice Address - Street 1:982 LEE ANN DR NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2957
Practice Address - Country:US
Practice Address - Phone:704-787-9355
Practice Address - Fax:704-787-9554
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9491122300000X
NC17304440351223G0001X
NC112401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist