Provider Demographics
NPI:1285179697
Name:DENTAL SPECIALTIES 2ND DR, JESSE A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DENTAL SPECIALTIES 2ND DR, JESSE A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:JESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-951-9304
Mailing Address - Street 1:15401 ANACAPA RD STE 3
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2466
Mailing Address - Country:US
Mailing Address - Phone:760-951-9304
Mailing Address - Fax:951-396-3335
Practice Address - Street 1:15401 ANACAPA RD STE 3
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2466
Practice Address - Country:US
Practice Address - Phone:760-951-9304
Practice Address - Fax:951-396-3335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23785305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service