Healthcare Provider Details

I. General information

NPI: 1972894673
Provider Name (Legal Business Name): MINA ABRAHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23535 AVALON BLVD
CARSON CA
90745-5522
US

IV. Provider business mailing address

23535 AVALON BLVD
CARSON CA
90745-5522
US

V. Phone/Fax

Practice location:
  • Phone: 310-835-5550
  • Fax: 310-834-5550
Mailing address:
  • Phone: 310-835-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number60206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: