Healthcare Provider Details

I. General information

NPI: 1467696278
Provider Name (Legal Business Name): JAY KENNETH HUFFAKER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 N LARCHMONT BLVD
LOS ANGELES CA
90004-3014
US

IV. Provider business mailing address

402 N LARCHMONT BLVD
LOS ANGELES CA
90004-3014
US

V. Phone/Fax

Practice location:
  • Phone: 323-467-1472
  • Fax: 323-467-1950
Mailing address:
  • Phone: 323-467-1472
  • Fax: 323-467-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number30091
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: