Healthcare Provider Details

I. General information

NPI: 1750405288
Provider Name (Legal Business Name): E JAN DAVIDIAN DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6886 INDIANA AVE
RIVERSIDE CA
92506-4218
US

IV. Provider business mailing address

6886 INDIANA AVE
RIVERSIDE CA
92506-4218
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-6030
  • Fax: 951-682-9243
Mailing address:
  • Phone: 951-682-6030
  • Fax: 951-682-9243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDV17057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: