=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265321699
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA JADE PUCCI DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2025
-----------------------------------------------------
Last Update Date | 07/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1707 W HIGHWAY 50
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-1624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-206-5488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 618 E 20TH ST
-----------------------------------------------------
City | ALTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62002-3540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-493-8587
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2025027647
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019.036217
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------