Provider Demographics
NPI:1104349760
Name:JESSE M. FA, DDS, INC
Entity type:Organization
Organization Name:JESSE M. FA, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:925-757-2217
Mailing Address - Street 1:2730 LONE TREE WAY STE 7
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-4964
Mailing Address - Country:US
Mailing Address - Phone:925-757-2217
Mailing Address - Fax:925-757-6417
Practice Address - Street 1:2730 LONE TREE WAY STE 7
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4964
Practice Address - Country:US
Practice Address - Phone:925-757-2217
Practice Address - Fax:925-757-6417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty