Provider Demographics
NPI:1063725364
Name:PADILLA, JESSE ANTHONY
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:ANTHONY
Last Name:PADILLA
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 1:200 W SHAW AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-3684
Mailing Address - Country:US
Mailing Address - Phone:559-325-6161
Mailing Address - Fax:
Practice Address - Street 1:200 W SHAW AVE STE 110
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3684
Practice Address - Country:US
Practice Address - Phone:559-325-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant