Provider Demographics
NPI:1104915305
Name:JARDINE, LYDIA (RDH)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:JARDINE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94592-1168
Mailing Address - Country:US
Mailing Address - Phone:510-437-3615
Mailing Address - Fax:510-437-3034
Practice Address - Street 1:BUILDING ONE
Practice Address - Street 2:USCG COAST GUARD ISLAND
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501
Practice Address - Country:US
Practice Address - Phone:510-437-3615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH 20602124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist