Healthcare Provider Details

I. General information

NPI: 1851661169
Provider Name (Legal Business Name): MODERN SMILES DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 N HOLLYWOOD WAY # 213
BURBANK CA
91505-2814
US

IV. Provider business mailing address

827 N HOLLYWOOD WAY # 213
BURBANK CA
91505-2814
US

V. Phone/Fax

Practice location:
  • Phone: 818-588-9585
  • Fax:
Mailing address:
  • Phone: 818-588-9585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number61124
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ANDREW MARTINEZ
Title or Position: OFFICE MANAGER / SECRETARY
Credential:
Phone: 818-855-9585