Healthcare Provider Details

I. General information

NPI: 1407334683
Provider Name (Legal Business Name): JOSE IGNACIO PEREA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12300 WILSHIRE BLVD STE 404
LOS ANGELES CA
90025-1061
US

IV. Provider business mailing address

12300 WILSHIRE BLVD STE 404
LOS ANGELES CA
90025-1061
US

V. Phone/Fax

Practice location:
  • Phone: 310-207-2272
  • Fax: 424-293-2623
Mailing address:
  • Phone: 310-207-2272
  • Fax: 424-293-2623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number48537
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: