Healthcare Provider Details

I. General information

NPI: 1669823829
Provider Name (Legal Business Name): TALITHA MARIE JESSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TALITHA MARIE JESSE KHORASANI DDS

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 E BELL RD STE 106
PHOENIX AZ
85032-9342
US

IV. Provider business mailing address

16333 RIDGEHAVEN DR UNIT 1002
SAN LEANDRO CA
94578-1481
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-9530
  • Fax:
Mailing address:
  • Phone: 925-719-0019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number108674
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD012005
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: