Provider Demographics
NPI:1215342563
Name:WEISSICH, JACOB (DDS)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WEISSICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9680 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-1456
Mailing Address - Country:US
Mailing Address - Phone:917-536-1011
Mailing Address - Fax:
Practice Address - Street 1:290 N WAYTE LN
Practice Address - Street 2:SURABIAN DENTAL CENTER
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2124
Practice Address - Country:US
Practice Address - Phone:559-459-5725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program