Provider Demographics
NPI:1386745644
Name:ADAMS, JILL A (DDS)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:ADAMS
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 1:1414 SHINING ARMOR LN
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-5473
Mailing Address - Country:US
Mailing Address - Phone:765-412-6582
Mailing Address - Fax:
Practice Address - Street 1:4379 RIDGEWOOD CENTER DR
Practice Address - Street 2:STE 102
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-8323
Practice Address - Country:US
Practice Address - Phone:703-680-7950
Practice Address - Fax:703-680-7953
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010250A122300000X
VA401412281122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID12010250AOtherSTATE LICENSE
ID200327070Medicaid