Provider Demographics
NPI:1902930936
Name:JARA, JAVIER ELIECER (DDS)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:ELIECER
Last Name:JARA
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 1:16619 COHASSET ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-2810
Mailing Address - Country:US
Mailing Address - Phone:818-901-1586
Mailing Address - Fax:
Practice Address - Street 1:3129 N SAN FERNANDO RD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90065-1412
Practice Address - Country:US
Practice Address - Phone:323-257-7744
Practice Address - Fax:323-257-5430
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD50759122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist