Provider Demographics
NPI:1538176425
Name:WASSEM, JEFFREY DAVID (DDS)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DAVID
Last Name:WASSEM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:JEFF
Other - Middle Name:DAVID
Other - Last Name:WASSEM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:500 E OLIVE AVE
Mailing Address - Street 2:SUITE #104
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-2171
Mailing Address - Country:US
Mailing Address - Phone:818-846-9951
Mailing Address - Fax:
Practice Address - Street 1:500 E OLIVE AVE
Practice Address - Street 2:SUITE #104
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91501-2171
Practice Address - Country:US
Practice Address - Phone:818-846-9951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32199122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB3219901OtherDENTI CAL
735947OtherUNITED CONCORDIA INSURANC