Provider Demographics
NPI:1952726499
Name:JACOB VAYNER DMD A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:JACOB VAYNER DMD A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:ESTHETIC SMILE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:J
Authorized Official - Last Name:VAYNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-344-4929
Mailing Address - Street 1:19231 VICTORY BLVD STE 216
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6338
Mailing Address - Country:US
Mailing Address - Phone:818-344-4929
Mailing Address - Fax:
Practice Address - Street 1:19231 VICTORY BLVD STE 216
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-6338
Practice Address - Country:US
Practice Address - Phone:818-344-4929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58805122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty