Provider Demographics
NPI:1962519272
Name:REZNICK, JAY BRIAN (MD, DMD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:BRIAN
Last Name:REZNICK
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18372 CLARK ST
Mailing Address - Street 2:SUITE 224
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3508
Mailing Address - Country:US
Mailing Address - Phone:818-996-1200
Mailing Address - Fax:818-996-1325
Practice Address - Street 1:18372 CLARK ST
Practice Address - Street 2:SUITE 224
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3508
Practice Address - Country:US
Practice Address - Phone:818-996-1200
Practice Address - Fax:818-996-1325
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374851223S0112X
CAA055148204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG25364Medicare UPIN
CAWA55148BMedicare ID - Type Unspecified
CAWA55148AMedicare ID - Type UnspecifiedENCINO OFFICE