MEDICARE: JESO ADVANCED FAMILY DENTISTRY

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	1223G0001X	General Practice Dentistry	DS036147	PA

General Provider Information

NPI Number	:	1952449555
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESO ADVANCED FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	233 MCCLELLAN ST
Second Line	:	SUITE A
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-1918
Country	:	US
Telephone Number	:	215-755-6626
Fax Number	:	215-467-7151

Provider Business Practice Location Address
First Line	:	233 MCCLELLAN ST
Second Line	:	SUITE A
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-1918
Country	:	US
Telephone Number	:	215-755-6626
Fax Number	:	215-467-7151

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. ESOCHI JOAN IHEOMA
Credential	:	D.D.S
Telephone Number	:	215-755-6626

Provider Enumeration Date	:	02/03/2007
Last Update Date	:	09/20/2010

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