Provider Demographics
NPI:1871079079
Name:MISKAVIGE, JESSICA L (DDS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:MISKAVIGE
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 1:212 S 4TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4781
Mailing Address - Country:US
Mailing Address - Phone:701-757-2100
Mailing Address - Fax:
Practice Address - Street 1:212 S 4TH ST STE 101
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4776
Practice Address - Country:US
Practice Address - Phone:701-757-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2346122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist