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General NPI Number Information
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NPI Number | 1114561198
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Entity Type | Individual
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Provider Name | JESSE HUSTON DMD
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Gender | Male
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Dates
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Enumeration Date | 11/01/2019
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Last Update Date | 09/19/2023
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Provider Practice Location Address
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Address Line | 1465 N FRONTAGE RD
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City | HASTINGS
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State | MN
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Zip | 55033-2355
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Country | US
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Telephone | 831-826-1099
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Fax |
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Provider Business Mailing Address
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Address Line | 2555 FENTON PKWY APT 315
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City | SAN DIEGO
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State | CA
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Zip | 92108-6772
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Country | US
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Telephone | 831-261-0999
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D15004
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DDS104406
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License Number State | CA
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