MEDICARE: JAVIER ELIECER JARA D.D.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	122300000X	Dentist	D50759	CA

General Provider Information

NPI Number	:	1902930936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAVIER ELIECER JARA D.D.S

Provider Business Mailing Address
First Line	:	16619 COHASSET ST
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91406-2810
Country	:	US
Telephone Number	:	818-901-1586
Fax Number	:

Provider Business Practice Location Address
First Line	:	3129 N SAN FERNANDO RD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90065-1412
Country	:	US
Telephone Number	:	323-257-7744
Fax Number	:	323-257-5430

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

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/08/2007

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