Healthcare Provider Details

I. General information

NPI: 1689295008
Provider Name (Legal Business Name): JORDAN SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6336 FLORENCE AVE
BELL GARDENS CA
90201-4732
US

IV. Provider business mailing address

15308 GLEN RIDGE DR
CHINO HILLS CA
91709-4224
US

V. Phone/Fax

Practice location:
  • Phone: 213-556-1746
  • Fax:
Mailing address:
  • Phone: 714-661-6309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number105202
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: