Provider Demographics
NPI:1154778710
Name:REISIG, JESSIE ELLEN (DMD)
Entity type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:ELLEN
Last Name:REISIG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 E 79TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0216
Mailing Address - Country:US
Mailing Address - Phone:212-772-7668
Mailing Address - Fax:
Practice Address - Street 1:65 E 79TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0216
Practice Address - Country:US
Practice Address - Phone:212-772-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0602801223E0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty