MEDICARE: JERRY MORANA, JR., DDS, A PROFESSIONAL CORPORATION

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	1223G0001X	General Practice Dentistry	43372	CA

General Provider Information

NPI Number	:	1316135122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JERRY MORANA, JR., DDS, A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	6117 BROCKTON AVE
Second Line	:	SUITE 103
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-2232
Country	:	US
Telephone Number	:	951-686-7420
Fax Number	:	951-686-6251

Provider Business Practice Location Address
First Line	:	6117 BROCKTON AVE
Second Line	:	SUITE 103
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-2232
Country	:	US
Telephone Number	:	951-686-7420
Fax Number	:	951-686-6251

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JERRY MORANA JR.
Credential	:	D.D.S.
Telephone Number	:	951-686-7420

Provider Enumeration Date	:	10/05/2007
Last Update Date	:	10/05/2007

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