Healthcare Provider Details

I. General information

NPI: 1265321699
Provider Name (Legal Business Name): JESSICA JADE PUCCI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 W HIGHWAY 50
O FALLON IL
62269-1624
US

IV. Provider business mailing address

618 E 20TH ST
ALTON IL
62002-3540
US

V. Phone/Fax

Practice location:
  • Phone: 618-206-5488
  • Fax:
Mailing address:
  • Phone: 573-493-8587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2025027647
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.036217
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: