MEDICARE: JORDAN CHELSEY DOUGLAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	105748	CA

General Provider Information

NPI Number	:	1063011799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN CHELSEY DOUGLAS

Provider Business Mailing Address
First Line	:	770 S GRAND AVE APT 5066
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-3949
Country	:	US
Telephone Number	:	678-749-9540
Fax Number	:

Provider Business Practice Location Address
First Line	:	460 N MCKINLEY ST
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92879-3405
Country	:	US
Telephone Number	:	951-531-9693
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2020
Last Update Date	:	10/23/2020

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Directions to “ JORDAN CHELSEY DOUGLAS ” Practice Location

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