MEDICARE: JONATHAN DYE 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	1223G0001X	General Practice Dentistry	DDS104487	CA

General Provider Information

NPI Number	:	1518504497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN DYE DDS

Provider Business Mailing Address
First Line	:	1626 PALO ALTO ST APT 102
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90026-5052
Country	:	US
Telephone Number	:	808-634-6293
Fax Number	:

Provider Business Practice Location Address
First Line	:	1626 PALO ALTO ST APT 102
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90026-5052
Country	:	US
Telephone Number	:	808-634-6293
Fax Number	:

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

Provider Enumeration Date	:	12/10/2019
Last Update Date	:	12/10/2019

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