Healthcare Provider Details

I. General information

NPI: 1770487563
Provider Name (Legal Business Name): ALYSSA SELOVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 KALMUS DR STE C225
COSTA MESA CA
92626-7965
US

IV. Provider business mailing address

151 KALMUS DR STE C225
COSTA MESA CA
92626-7965
US

V. Phone/Fax

Practice location:
  • Phone: 949-822-9818
  • Fax:
Mailing address:
  • Phone: 949-822-9818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number29371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: