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Provider Information for 1114419611

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1114419611

Calendar   Last Updated:  2021-03-19
  Certification Date:  2021-03-19


Name Value
NPI 1114419611
Enumeration Date 2018-05-31
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 1818 PELHAM AVE APT 108
LOS ANGELES, CA 90025-4756
United States

Phone: 310-666-3276 | Fax:
View Map External Link
Primary Practice Address 6950 N PARAMOUNT BLVD
LONG BEACH, CA 90805-1863
United States

Phone: 562-278-3080 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223X0400X - Dentist Orthodontics and Dentofacial Orthopedics CA 102324