Healthcare Provider Details

I. General information

NPI: 1558791079
Provider Name (Legal Business Name): ZAK DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 LONG BEACH BLVD SUITE B6
LONG BEACH CA
90807-4022
US

IV. Provider business mailing address

3620 LONG BEACH BLVD SUITE B6
LONG BEACH CA
90807-4022
US

V. Phone/Fax

Practice location:
  • Phone: 562-426-6458
  • Fax: 310-734-1546
Mailing address:
  • Phone: 562-426-6458
  • Fax: 310-734-1546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ILYA ZAK
Title or Position: DENTIST/OWNER/CEO
Credential: D.D.S.
Phone: 310-706-5273