Healthcare Provider Details

I. General information

NPI: 1629557152
Provider Name (Legal Business Name): JIA TIAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 BLOSSOM HILL RD STE 150
SAN JOSE CA
95123
US

IV. Provider business mailing address

393 BLOSSOM HILL RD STE 150
SAN JOSE CA
95123-1655
US

V. Phone/Fax

Practice location:
  • Phone: 408-629-3366
  • Fax:
Mailing address:
  • Phone: 510-901-1312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number102957
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: