Provider Demographics
NPI:1396706669
Name:RONALD D JESSUP DMD PC
Entity type:Organization
Organization Name:RONALD D JESSUP DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:JESSUP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:276-628-8164
Mailing Address - Street 1:14245 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24202-4317
Mailing Address - Country:US
Mailing Address - Phone:276-628-8164
Mailing Address - Fax:276-644-3145
Practice Address - Street 1:14245 LEE HWY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-4317
Practice Address - Country:US
Practice Address - Phone:276-628-8164
Practice Address - Fax:276-644-3145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1223G0001X1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA164996Medicaid