Healthcare Provider Details

I. General information

NPI: 1194879627
Provider Name (Legal Business Name): 6TH STREET FAMILY DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 W 6TH STREET SUITE 109
LOS ANGELES CA
90057
US

IV. Provider business mailing address

2065 W 6TH STREET SUITE 109
LOS ANGELES CA
90057
US

V. Phone/Fax

Practice location:
  • Phone: 213-484-2100
  • Fax: 213-484-1474
Mailing address:
  • Phone: 213-484-2100
  • Fax: 213-484-1474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number41084
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number39963
License Number StateCA

VIII. Authorized Official

Name: SUSAN HAZANY
Title or Position: PARTNER
Credential: DDS
Phone: 213-484-2100