MEDICARE: JESSE M. FA, DDS, INC

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
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	55360	CA

General Provider Information

NPI Number	:	1649689597
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSE M. FA, DDS, INC

Provider Business Mailing Address
First Line	:	2201 BALFOUR RD STE E
Second Line	:
City	:	BRENTWOOD
State	:	CA
Zip	:	94513-4927
Country	:	US
Telephone Number	:	925-308-7908
Fax Number	:	925-308-7910

Provider Business Practice Location Address
First Line	:	2201 BALFOUR RD STE E
Second Line	:
City	:	BRENTWOOD
State	:	CA
Zip	:	94513-4927
Country	:	US
Telephone Number	:	925-308-7908
Fax Number	:	925-308-7910

Authorized Official
Title or Position	:	OWNER
Name	:	JESSE MICHAEL FA
Credential	:	DDS
Telephone Number	:	925-757-2217

Provider Enumeration Date	:	08/05/2014
Last Update Date	:	04/08/2020

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