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General NPI Number Information
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NPI Number | 1548574767
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Entity Type | Individual
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Provider Name | JACK ELLIOT WASSERSTEIN DDS
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Gender | Male
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Dates
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Enumeration Date | 07/29/2010
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Last Update Date | 07/29/2010
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Provider Practice Location Address
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Address Line | 27450 TOURNEY RD SUITE 100
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City | VALENCIA
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State | CA
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Zip | 91355-1828
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Country | US
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Telephone | 661-254-8484
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Fax | 661-254-8669
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Provider Business Mailing Address
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Address Line | 27450 TOURNEY RD SUITE 100
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City | VALENCIA
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State | CA
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Zip | 91355-1828
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Country | US
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Telephone | 661-254-8484
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Fax | 661-254-8669
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 36297
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License Number State | CA
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