Provider Demographics
NPI:1104556265
Name:PICENO, JESUS ARMANDO
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:ARMANDO
Last Name:PICENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 BEYER BLVD APT 203
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-1308
Mailing Address - Country:US
Mailing Address - Phone:619-864-2022
Mailing Address - Fax:
Practice Address - Street 1:CALLE 6TA #2245 1A
Practice Address - Street 2:
Practice Address - City:TUJUANA
Practice Address - State:TIJUANA
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:619-864-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ29644841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD3670918Medicaid