Provider Demographics
NPI:1699859074
Name:FOSQUE-JOHNSON, JACQUELINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:FOSQUE-JOHNSON
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 1:256 COUNTRY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-6653
Mailing Address - Country:US
Mailing Address - Phone:914-472-0922
Mailing Address - Fax:
Practice Address - Street 1:305 E 161ST ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-3535
Practice Address - Country:US
Practice Address - Phone:718-579-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038094-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice