Provider Demographics
NPI:1255653655
Name:CARRILLO, JESSICA (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 STERLING OAKS DR APT 230
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-9460
Mailing Address - Country:US
Mailing Address - Phone:530-570-4974
Mailing Address - Fax:
Practice Address - Street 1:100 STERLING OAKS DR APT 230
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-9460
Practice Address - Country:US
Practice Address - Phone:530-570-4974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA591441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice