Healthcare Provider Details

I. General information

NPI: 1275944167
Provider Name (Legal Business Name): JUST SMILE DENTAL CENTER,DENTAL GROUP OF ADONIS REGALA,D.D.S., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1269 S UNION AVE
LOS ANGELES CA
90015-2043
US

IV. Provider business mailing address

1269 S UNION AVE
LOS ANGELES CA
90015-2043
US

V. Phone/Fax

Practice location:
  • Phone: 213-251-1400
  • Fax:
Mailing address:
  • Phone: 213-251-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number43555
License Number StateCA

VIII. Authorized Official

Name: ADONIS MANALO REGALA
Title or Position: DENTIST
Credential: DDS
Phone: 213-251-1400