Provider Demographics
NPI:1992223440
Name:MACHADO, JESSICA PHAN (DMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:PHAN
Last Name:MACHADO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:THUY
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:16008 LEGACY RD UNIT 307
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-2812
Mailing Address - Country:US
Mailing Address - Phone:949-392-2827
Mailing Address - Fax:
Practice Address - Street 1:3991 GRAND AVE STE D
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-5442
Practice Address - Country:US
Practice Address - Phone:909-591-0077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA653001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty