Provider Demographics
NPI:1285870188
Name:JACQUELINE B SMITH DDS PLLC
Entity type:Organization
Organization Name:JACQUELINE B SMITH DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:BROWN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-424-0095
Mailing Address - Street 1:1385 FORDHAM DR STE 106
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-5345
Mailing Address - Country:US
Mailing Address - Phone:757-424-0095
Mailing Address - Fax:757-424-2226
Practice Address - Street 1:1385 FORDHAM DR STE 106
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5345
Practice Address - Country:US
Practice Address - Phone:757-424-0095
Practice Address - Fax:757-424-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014116051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899018VMedicaid