Provider Demographics
NPI:1528214228
Name:OLIMPIADA, JORN N (DDS)
Entity Type:Individual
Prefix:
First Name:JORN
Middle Name:N
Last Name:OLIMPIADA
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 1:15401 HESPERIAN BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-3900
Mailing Address - Country:US
Mailing Address - Phone:510-317-9439
Mailing Address - Fax:
Practice Address - Street 1:15401 HESPERIAN BLVD STE F
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-3900
Practice Address - Country:US
Practice Address - Phone:510-317-9439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA475421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD47542Medicaid