MEDICARE: DR. JESSE J. PUNCH DMD, MSD

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	65076	CA

General Provider Information

NPI Number	:	1679943484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSE J. PUNCH DMD, MSD

Provider Business Mailing Address
First Line	:	4375 FIRST ST
Second Line	:
City	:	LIVERMORE
State	:	CA
Zip	:	94551-4912
Country	:	US
Telephone Number	:	925-294-9288
Fax Number	:

Provider Business Practice Location Address
First Line	:	4375 FIRST ST
Second Line	:
City	:	LIVERMORE
State	:	CA
Zip	:	94551-4912
Country	:	US
Telephone Number	:	925-294-9288
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2015
Last Update Date	:	12/29/2015

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