Healthcare Provider Details

I. General information

NPI: 1417776089
Provider Name (Legal Business Name): TOP DENTAL HUNTINGTON PARK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 10/09/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6416 SANTA FE AVE
HUNTINGTON PARK CA
90255
US

IV. Provider business mailing address

2707 WEST OLYMPIC BLVD 202
LOS ANGELES CA
90006
US

V. Phone/Fax

Practice location:
  • Phone: 844-741-8600
  • Fax:
Mailing address:
  • Phone: 415-602-2208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ANDREW LEE
Title or Position: PRESIDENT
Credential:
Phone: 415-602-2208