MEDICARE: JESSICA PHAN MACHADO DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	65300	CA

General Provider Information

NPI Number	:	1992223440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA PHAN MACHADO DMD

Provider Business Mailing Address
First Line	:	16008 LEGACY RD UNIT 307
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92782-2812
Country	:	US
Telephone Number	:	949-392-2827
Fax Number	:

Provider Business Practice Location Address
First Line	:	3991 GRAND AVE STE D
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-5442
Country	:	US
Telephone Number	:	909-591-0077
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2017
Last Update Date	:	09/05/2017

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