Provider Demographics
NPI:1811481575
Name:JASON KENJI REYDA, DDS, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JASON KENJI REYDA, DDS, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:KENJI
Authorized Official - Last Name:REYDA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-585-3160
Mailing Address - Street 1:5200 SNYDER LN STE 1
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2931
Mailing Address - Country:US
Mailing Address - Phone:707-585-3160
Mailing Address - Fax:
Practice Address - Street 1:5200 SNYDER LN STE 1
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2931
Practice Address - Country:US
Practice Address - Phone:707-585-3160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty