Healthcare Provider Details

I. General information

NPI: 1043863061
Provider Name (Legal Business Name): MARIO AMIDI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 W ROSECRANS AVE STE A&B
COMPTON CA
90222-3821
US

IV. Provider business mailing address

18411 HATTERAS ST UNIT 114
TARZANA CA
91356-1985
US

V. Phone/Fax

Practice location:
  • Phone: 312-274-4524
  • Fax:
Mailing address:
  • Phone: 818-357-1158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number104189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: