Provider Demographics
NPI:1700210630
Name:HAYATE, JESSICA FORTUNEE (DMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:FORTUNEE
Last Name:HAYATE
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 1:3370 NE 190TH ST APT 1409
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-2416
Mailing Address - Country:US
Mailing Address - Phone:786-431-7216
Mailing Address - Fax:
Practice Address - Street 1:16200 NE 13TH AVE
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4608
Practice Address - Country:US
Practice Address - Phone:305-760-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN203101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice