Healthcare Provider Details

I. General information

NPI: 1013890284
Provider Name (Legal Business Name): JACOB ALLEN ENJATI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24647 LAWTON AVE
LOMA LINDA CA
92354-3323
US

IV. Provider business mailing address

24647 LAWTON AVE
LOMA LINDA CA
92354-3323
US

V. Phone/Fax

Practice location:
  • Phone: 509-990-3031
  • Fax:
Mailing address:
  • Phone: 509-990-3031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number112095
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: