Provider Demographics
NPI:1669823829
Name:JESSE, TALITHA MARIE
Entity type:Individual
Prefix:
First Name:TALITHA
Middle Name:MARIE
Last Name:JESSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TALITHA
Other - Middle Name:MARIE JESSE
Other - Last Name:KHORASANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:16333 RIDGEHAVEN DR UNIT 1002
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1481
Mailing Address - Country:US
Mailing Address - Phone:925-719-0019
Mailing Address - Fax:
Practice Address - Street 1:4550 E BELL RD STE 106
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-9342
Practice Address - Country:US
Practice Address - Phone:602-344-9530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108674122300000X
AZ390200000X
AZD0120051223G0001X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst