Provider Demographics
NPI:1912072745
Name:KOLESAR, JERRY W (DMD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:W
Last Name:KOLESAR
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 1:1122 N BRAND BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-2570
Mailing Address - Country:US
Mailing Address - Phone:818-242-2667
Mailing Address - Fax:818-242-2668
Practice Address - Street 1:1122 N BRAND BLVD STE 102
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2570
Practice Address - Country:US
Practice Address - Phone:818-242-2667
Practice Address - Fax:818-242-2668
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0369551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice