Provider Demographics
NPI:1568767788
Name:ESCOBAR, JERNELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERNELL
Middle Name:
Last Name:ESCOBAR
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 1:2099 DARYLVIEW CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95138-2476
Mailing Address - Country:US
Mailing Address - Phone:408-857-0991
Mailing Address - Fax:408-227-0717
Practice Address - Street 1:5758 SANTA TERESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-4540
Practice Address - Country:US
Practice Address - Phone:408-227-0910
Practice Address - Fax:408-227-0717
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA548321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice