MEDICARE: DR. JASON T CHIAKOWSKY D.D.S., M.S.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	40922	CA

General Provider Information

NPI Number	:	1619189271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON T CHIAKOWSKY D.D.S., M.S.

Provider Business Mailing Address
First Line	:	11354 MOUNTAIN VIEW AVE STE B
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-3855
Country	:	US
Telephone Number	:	909-799-7595
Fax Number	:	909-796-2950

Provider Business Practice Location Address
First Line	:	11354 MOUNTAIN VIEW AVE STE B
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-3855
Country	:	US
Telephone Number	:	909-799-7595
Fax Number	:	909-796-2950

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

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	02/19/2013

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