Provider Demographics
NPI:1770906992
Name:DEFAZIO, JESSICA FRANCES (DDS)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:FRANCES
Last Name:DEFAZIO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:FRANCES
Other - Last Name:KRAVIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3776 DOVE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3979
Mailing Address - Country:US
Mailing Address - Phone:414-491-4003
Mailing Address - Fax:
Practice Address - Street 1:345 E 24TH ST # 9W
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4020
Practice Address - Country:US
Practice Address - Phone:414-491-4003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000000000000000000001223P0221X
CA641731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry