Healthcare Provider Details

I. General information

NPI: 1508911884
Provider Name (Legal Business Name): DAVID CHIH-YUAN JEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 N RIVERSIDE AVE
RIALTO CA
92376-8062
US

IV. Provider business mailing address

1727 N RIVERSIDE AVE
RIALTO CA
92376-8062
US

V. Phone/Fax

Practice location:
  • Phone: 909-961-2068
  • Fax:
Mailing address:
  • Phone: 626-318-6318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number36159
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: