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Provider Information for 1710069349

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: 1710069349

Calendar   Last Updated:  2007-07-08
  Certification Date: 


Name Value
NPI 1710069349
Enumeration Date 2006-10-20
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 750 S SANTA FE AVE
GLENDORA, CA 91740-4366
United States

Phone: 818-834-2858 | Fax:
View Map External Link
Primary Practice Address 13682 VAN NUYS BLVD
PACOIMA, CA 91331-3616
United States

Phone: 818-834-2858 | Fax: 818-834-2698
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 1223G0001X - Dentist General Practice CA 39855