Provider Demographics
NPI:1649689597
Name:JESSE M. FA, DDS, INC
Entity type:Organization
Organization Name:JESSE M. FA, DDS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:925-757-2217
Mailing Address - Street 1:2201 BALFOUR RD STE E
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-4927
Mailing Address - Country:US
Mailing Address - Phone:925-308-7908
Mailing Address - Fax:925-308-7910
Practice Address - Street 1:2201 BALFOUR RD STE E
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-4927
Practice Address - Country:US
Practice Address - Phone:925-308-7908
Practice Address - Fax:925-308-7910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA553601223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty