Healthcare Provider Details

I. General information

NPI: 1326961772
Provider Name (Legal Business Name): JASMINE DARRYL FORTUNA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JASMINE FORTUNA DMD

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1436 CLARKE ST
SAN LEANDRO CA
94577-3635
US

IV. Provider business mailing address

2262 REGATTA CT
SAN LEANDRO CA
94579-2708
US

V. Phone/Fax

Practice location:
  • Phone: 510-939-7246
  • Fax:
Mailing address:
  • Phone: 510-760-7456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: