Provider Demographics
NPI:1356680342
Name:MACAGNO, JESSICA JOMAYRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:JOMAYRA
Last Name:MACAGNO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 NW 129TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2328
Mailing Address - Country:US
Mailing Address - Phone:305-303-5172
Mailing Address - Fax:786-953-4269
Practice Address - Street 1:3750 W 16TH AVE
Practice Address - Street 2:236-U
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4654
Practice Address - Country:US
Practice Address - Phone:305-231-0545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN199741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice