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NPI Code Detail

MEDICARE: JOSE R DE JESUS DMD

MEDICARE: JOSE R DE JESUS DMD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentist1817PR
21223G0001XGeneral Practice Dentistry12041NC

General Provider Information

NPI Number : 1588650097
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOSE R DE JESUS DMD
Provider Business Mailing Address
First Line : 200 E 2ND AVE
Second Line :
City : GASTONIA
State : NC
Zip : 28052-4358
Country : US
Telephone Number : 704-874-1904
Fax Number :
Provider Business Practice Location Address
First Line : 991 W HUDSON BLVD
Second Line :
City : GASTONIA
State : NC
Zip : 28052-6430
Country : US
Telephone Number : 704-853-5191
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/21/2005
Last Update Date : 10/22/2021

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Directions to “ JOSE R DE JESUS DMD” Practice Location

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