Provider Demographics
NPI:1154711521
Name:JAY, EDMUND WALT (DDS)
Entity type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:WALT
Last Name:JAY
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 1:3737 MORAGA AVE
Mailing Address - Street 2:STE. B-300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5404
Mailing Address - Country:US
Mailing Address - Phone:858-270-0682
Mailing Address - Fax:858-270-0685
Practice Address - Street 1:3737 MORAGA AVE
Practice Address - Street 2:STE. B-300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5404
Practice Address - Country:US
Practice Address - Phone:858-270-0682
Practice Address - Fax:858-270-0685
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36384122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist