Provider Demographics
NPI:1720587090
Name:BRICENO RODRIGUEZ, JESSICA GISELLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:GISELLE
Last Name:BRICENO RODRIGUEZ
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 1:326 N RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-5926
Mailing Address - Country:US
Mailing Address - Phone:909-875-1464
Mailing Address - Fax:
Practice Address - Street 1:326 N RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5926
Practice Address - Country:US
Practice Address - Phone:909-875-1464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102169122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist