MEDICARE: JAY KENNETH HUFFAKER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics	30091	CA

General Provider Information

NPI Number	:	1467696278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAY KENNETH HUFFAKER DDS

Provider Business Mailing Address
First Line	:	402 N LARCHMONT BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-3014
Country	:	US
Telephone Number	:	323-467-1472
Fax Number	:	323-467-1950

Provider Business Practice Location Address
First Line	:	402 N LARCHMONT BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-3014
Country	:	US
Telephone Number	:	323-467-1472
Fax Number	:	323-467-1950

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2009
Last Update Date	:	04/23/2009

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