Provider Demographics
NPI:1194860809
Name:CORRAL, JESSIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:
Last Name:CORRAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9396 GLENAIRE CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5775
Mailing Address - Country:US
Mailing Address - Phone:909-476-8145
Mailing Address - Fax:
Practice Address - Street 1:2600 OSWELL ST STE F
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-3159
Practice Address - Country:US
Practice Address - Phone:661-871-4132
Practice Address - Fax:661-872-0943
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA448571223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice