Provider Demographics
NPI:1346990835
Name:CONVERSE, JESSICA MICHELLE (DMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELLE
Last Name:CONVERSE
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 1:4859 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-6961
Mailing Address - Country:US
Mailing Address - Phone:619-838-7299
Mailing Address - Fax:
Practice Address - Street 1:781 SEQUOIA AVE
Practice Address - Street 2:
Practice Address - City:LINDSAY
Practice Address - State:CA
Practice Address - Zip Code:93247-1447
Practice Address - Country:US
Practice Address - Phone:559-562-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-27
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11649122300000X, 1223G0001X
390200000X
CA109883122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program