Individual
DR. JESSICA WALLACE MIRRIELEES
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
DMD
Contact information
Practice address
996 TANNER FORD BLVD, HANAHAN, SC 29410-4780
(843) 212-8810
Mailing address
11080 WAR ADMIRAL DR, UNION, KY 41091-7920
(859) 893-5128
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
8672
SC
122300000X
Dentist
8747
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7100176940
—
KY
Enumeration date
10/15/2009
Last updated
05/27/2021
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