Healthcare Provider Details

I. General information

NPI: 1417149212
Provider Name (Legal Business Name): ALEXEI I MIZIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 03/06/2009
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:
Mailing address:
  • Phone: 818-225-2211
  • Fax:

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:
Title or Position:
Credential:
Phone: