Healthcare Provider Details

I. General information

NPI: 1417091430
Provider Name (Legal Business Name): DAVID J.JO DDS MS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10600 MAGNOLIA AVE SUITE A
RIVERSIDE CA
92505-1819
US

IV. Provider business mailing address

10600 MAGNOLIA AVE SUITE A
RIVERSIDE CA
92505-1819
US

V. Phone/Fax

Practice location:
  • Phone: 951-359-8100
  • Fax:
Mailing address:
  • Phone: 951-359-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30682
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID JAEKWAN JO
Title or Position: PRESIDENT
Credential: D.D.S., M.S.
Phone: 951-359-8100