Healthcare Provider Details

I. General information

NPI: 1801156591
Provider Name (Legal Business Name): JESSICA LAUREN SPINELLA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 ERIE BLVD E
SYRACUSE NY
13210
US

IV. Provider business mailing address

910 ERIE BLVD E
SYRACUSE NY
13210-1048
US

V. Phone/Fax

Practice location:
  • Phone: 315-425-2468
  • Fax:
Mailing address:
  • Phone: 315-425-2468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number056643-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number056643-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: