Healthcare Provider Details

I. General information

NPI: 1477175073
Provider Name (Legal Business Name): ABRAHAM DDS DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2020
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: 310-834-5550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MINA T ABRAHAM
Title or Position: PRESIDENT
Credential:
Phone: 310-835-5550