Provider Demographics
NPI:1467696278
Name:HUFFAKER, JAY KENNETH (DDS)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:KENNETH
Last Name:HUFFAKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 N LARCHMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3014
Mailing Address - Country:US
Mailing Address - Phone:323-467-1472
Mailing Address - Fax:323-467-1950
Practice Address - Street 1:402 N LARCHMONT BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3014
Practice Address - Country:US
Practice Address - Phone:323-467-1472
Practice Address - Fax:323-467-1950
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300911223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics