Provider Demographics
NPI:1215585062
Name:ANNELLO, JINA C (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:JINA
Middle Name:C
Last Name:ANNELLO
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9220 SILVERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-7242
Mailing Address - Country:US
Mailing Address - Phone:916-337-4059
Mailing Address - Fax:
Practice Address - Street 1:2190 E BIDWELL ST
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-6453
Practice Address - Country:US
Practice Address - Phone:916-984-0304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA384861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty