Healthcare Provider Details

I. General information

NPI: 1225432875
Provider Name (Legal Business Name): SEAN K KUTLAY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2014
Last Update Date: 08/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11628 SANTA MONICA BLVD
LOS ANGELES CA
90025-2900
US

IV. Provider business mailing address

11865 ROCHESTER AVE UNIT 3
LOS ANGELES CA
90025-1417
US

V. Phone/Fax

Practice location:
  • Phone: 310-207-1060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number63976
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: