Provider Demographics
NPI:1801042817
Name:LAVI, JACOB JONATHAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:JONATHAN
Last Name:LAVI
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 1:18034 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3516
Mailing Address - Country:US
Mailing Address - Phone:310-404-8640
Mailing Address - Fax:
Practice Address - Street 1:2175 E CHEYENNE AVE STE 100
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-8438
Practice Address - Country:US
Practice Address - Phone:702-363-8889
Practice Address - Fax:702-566-8883
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-09
Last Update Date:2008-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4735T1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice