Healthcare Provider Details

I. General information

NPI: 1437893005
Provider Name (Legal Business Name): JESS JORDAN CAYETANO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 MDG UNIT 5142
APO AP
96368
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP BLDG 4554
JBSA LACKLAND TX
78236-5638
US

V. Phone/Fax

Practice location:
  • Phone: 544-630-4589
  • Fax:
Mailing address:
  • Phone: 210-292-0690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDE61302122
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE6132122
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE61302122
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE61302122
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: