Healthcare Provider Details

I. General information

NPI: 1316135122
Provider Name (Legal Business Name): JERRY MORANA, JR., DDS, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6117 BROCKTON AVE SUITE 103
RIVERSIDE CA
92506-2232
US

IV. Provider business mailing address

6117 BROCKTON AVE SUITE 103
RIVERSIDE CA
92506-2232
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-7420
  • Fax: 951-686-6251
Mailing address:
  • Phone: 951-686-7420
  • Fax: 951-686-6251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number43372
License Number StateCA

VIII. Authorized Official

Name: DR. JERRY MORANA JR.
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 951-686-7420