MEDICARE: DR. JONATHAN MARC GIDAN DDS

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	1223P0221X	Pediatric Dentistry	29280	CA

General Provider Information

NPI Number	:	1164639803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN MARC GIDAN DDS

Provider Business Mailing Address
First Line	:	12840 RIVERSIDE DR
Second Line	:	#504
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91607-3327
Country	:	US
Telephone Number	:	818-506-2424
Fax Number	:	818-563-6789

Provider Business Practice Location Address
First Line	:	12840 RIVERSIDE DR
Second Line	:	#504
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91607-3327
Country	:	US
Telephone Number	:	818-506-2424
Fax Number	:	818-563-6789

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/08/2007

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