Provider Demographics
NPI:1194160689
Name:RICHERT, JORDAN CHAY (DMD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:CHAY
Last Name:RICHERT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 OAK ST APT 740
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-4627
Mailing Address - Country:US
Mailing Address - Phone:480-358-8489
Mailing Address - Fax:
Practice Address - Street 1:895 MORAGA RD STE 6
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-5039
Practice Address - Country:US
Practice Address - Phone:925-283-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1021911223P0300X
WADE606582921223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics