Healthcare Provider Details

I. General information

NPI: 1568767788
Provider Name (Legal Business Name): JERNELL ESCOBAR D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5758 SANTA TERESA BLVD
SAN JOSE CA
95123-4540
US

IV. Provider business mailing address

2099 DARYLVIEW CT
SAN JOSE CA
95138-2476
US

V. Phone/Fax

Practice location:
  • Phone: 408-227-0910
  • Fax: 408-227-0717
Mailing address:
  • Phone: 408-857-0991
  • Fax: 408-227-0717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number54832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: