Provider Demographics
NPI:1164639803
Name:GIDAN, JONATHAN MARC (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MARC
Last Name:GIDAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:12840 RIVERSIDE DR
Mailing Address - Street 2:#504
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3327
Mailing Address - Country:US
Mailing Address - Phone:818-506-2424
Mailing Address - Fax:818-563-6789
Practice Address - Street 1:12840 RIVERSIDE DR
Practice Address - Street 2:#504
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3327
Practice Address - Country:US
Practice Address - Phone:818-506-2424
Practice Address - Fax:818-563-6789
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA292801223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry