Healthcare Provider Details

I. General information

NPI: 1053552562
Provider Name (Legal Business Name): CALABASAS CENTER FOR ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24013 VENTURA BLVD SUITE 100
CALABASAS CA
91302-1447
US

IV. Provider business mailing address

24013 VENTURA BLVD SUITE 100
CALABASAS CA
91302-1447
US

V. Phone/Fax

Practice location:
  • Phone: 818-225-2211
  • Fax: 818-225-7478
Mailing address:
  • Phone: 818-225-2211
  • Fax: 818-225-7478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number54286
License Number StateCA

VIII. Authorized Official

Name: DR. ALEXEI I MIZIN
Title or Position: PRESIDENT
Credential: DMD
Phone: 818-225-2211