Provider Demographics
NPI:1003016494
Name:JAY B. REZNICK, DMD, MD, INC.
Entity Type:Organization
Organization Name:JAY B. REZNICK, DMD, MD, INC.
Other - Org Name:SOUTHERN CALIFORNIA CENTER FOR ORAL & FACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:B
Authorized Official - Last Name:REZNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:818-996-1200
Mailing Address - Street 1:18372 CLARK ST
Mailing Address - Street 2:SUITE 224
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3508
Mailing Address - Country:US
Mailing Address - Phone:818-996-1200
Mailing Address - Fax:818-996-1325
Practice Address - Street 1:18372 CLARK ST
Practice Address - Street 2:SUITE 224
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3508
Practice Address - Country:US
Practice Address - Phone:818-996-1200
Practice Address - Fax:818-996-1325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0551481223P0106X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty