Healthcare Provider Details

I. General information

NPI: 1932235462
Provider Name (Legal Business Name): JESSE ZAVALA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5805 W. 35TH
CICERO IL
60804
US

IV. Provider business mailing address

3520 S. MARSHFIELD
CHICAGO IL
60609
US

V. Phone/Fax

Practice location:
  • Phone: 708-477-6207
  • Fax:
Mailing address:
  • Phone: 312-478-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.027256
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: