Provider Demographics
NPI:1407954621
Name:NAKAMURA, JESSIE S (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:S
Last Name:NAKAMURA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1552 N TRACY BLVD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-2903
Mailing Address - Country:US
Mailing Address - Phone:209-835-9111
Mailing Address - Fax:209-835-9169
Practice Address - Street 1:1552 N TRACY BLVD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-2903
Practice Address - Country:US
Practice Address - Phone:209-835-9111
Practice Address - Fax:209-835-9169
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA438501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice