Healthcare Provider Details

I. General information

NPI: 1689896458
Provider Name (Legal Business Name): EZEANI DDS DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 12/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20763 AVALON BLVD
CARSON CA
90746-3313
US

IV. Provider business mailing address

20763 AVALON BLVD
CARSON CA
90746-3313
US

V. Phone/Fax

Practice location:
  • Phone: 310-719-1865
  • Fax: 310-464-8304
Mailing address:
  • Phone: 310-719-1865
  • Fax: 310-464-8304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberCA39398
License Number StateCA

VIII. Authorized Official

Name: DR. HYACINTH EZEBILO EZEANI
Title or Position: DOCTOR
Credential: D.D.S
Phone: 310-719-1865