Basic Information
Provider Information
NPI: 1255712865
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LOE
FirstName: JESSICA
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: DMD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1040 FLYNN RD
Address2:  
City: CAMARILLO
State: CA
PostalCode: 930125092
CountryCode: US
TelephoneNumber: 8056733930
FaxNumber: 8056593217
Practice Location
Address1: 221 E VENTURA BLVD STE 126
Address2:  
City: OXNARD
State: CA
PostalCode: 930360277
CountryCode: US
TelephoneNumber: 8054363443
FaxNumber: 8054854590
Other Information
ProviderEnumerationDate: 06/10/2015
LastUpdateDate: 10/17/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X101485CAY Dental ProvidersDentistGeneral Practice

No ID Information.


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