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General NPI Number Information
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NPI Number | 1285179697
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Entity Type | Organization
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Legal Business Name | DENTAL SPECIALTIES 2ND DR, JESSE A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 12/21/2016
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Last Update Date | 12/21/2016
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Provider Practice Location Address
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Address Line | 15401 ANACAPA RD STE 3
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City | VICTORVILLE
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State | CA
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Zip | 92392-2466
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Country | US
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Telephone | 760-951-9304
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Fax | 951-396-3335
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Provider Business Mailing Address
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Address Line | 15401 ANACAPA RD STE 3
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City | VICTORVILLE
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State | CA
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Zip | 92392-2466
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Country | US
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Telephone | 760-951-9304
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Fax | 951-396-3335
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Authorized Official
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Title or Position | DDS/OWNER
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Name | JAMES JESSE
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Credential |
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Telephone | 760-951-9304
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 23785
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License Number State | CA
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