Provider Demographics
NPI:1295825065
Name:VAYNER, JACOB J (DMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:J
Last Name:VAYNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19231 VICTORY BLVD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6308
Mailing Address - Country:US
Mailing Address - Phone:818-344-4929
Mailing Address - Fax:818-344-6736
Practice Address - Street 1:19231 VICTORY BLVD
Practice Address - Street 2:SUITE 216
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-6308
Practice Address - Country:US
Practice Address - Phone:818-344-4929
Practice Address - Fax:818-344-6736
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA588051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice