Basic Information
| Provider Information | |||||||||
| NPI: | 1336695535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASSOUDA | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | US ARMY DENTAC: ATTN CREDENTIALS OFFICE | ||||||||
| Address2: | 9900 LINCOLN STREET, 2ND FLOOR | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539684079 | ||||||||
| FaxNumber: | 2539685919 | ||||||||
| Practice Location | |||||||||
| Address1: | JBLM DENTAC | ||||||||
| Address2: | 9900 LINCOLN SREET, 2ND FLOOR | ||||||||
| City: | APO | ||||||||
| State: | AA | ||||||||
| PostalCode: | 98431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027598448 | ||||||||
| FaxNumber: | 2539685919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2016 | ||||||||
| LastUpdateDate: | 08/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 9738 | KY | Y | Dental Providers | Dentist | General Practice |
No ID Information.