Provider Demographics
NPI:1114561198
Name:HUSTON, JESSE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:HUSTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 FENTON PKWY APT 315
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-6772
Mailing Address - Country:US
Mailing Address - Phone:831-261-0999
Mailing Address - Fax:
Practice Address - Street 1:1465 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-2355
Practice Address - Country:US
Practice Address - Phone:831-826-1099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND15004122300000X
CADDS1044061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice