Basic Information
| Provider Information | |||||||||
| NPI: | 1285068239 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CICONE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1455 E WHITESTONE BLVD STE 127 | ||||||||
| Address2: | |||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786135031 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1455 E WHITESTONE BLVD STE 127 | ||||||||
| Address2: | |||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122597171 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2013 | ||||||||
| LastUpdateDate: | 07/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 62635 | CA | N | Dental Providers | Dentist | 390200000X | 62635 | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 122300000X | 33959 | TX | Y | Dental Providers | Dentist |
No ID Information.