Healthcare Provider Details

I. General information

NPI: 1134262322
Provider Name (Legal Business Name): DERSHSUAN LII D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 N.WILMINGTON AVE
COMPTON CA
90222
US

IV. Provider business mailing address

1625 N CEDARCREST DR
BREA CA
92821
US

V. Phone/Fax

Practice location:
  • Phone: 310-603-1332
  • Fax: 310-603-2726
Mailing address:
  • Phone: 714-256-2653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number41943
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: