Healthcare Provider Details

I. General information

NPI: 1639386766
Provider Name (Legal Business Name): ROBERT JOSEPH VIRATA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1327 S WESTGATE AVE APT 303
LOS ANGELES CA
90025-1491
US

IV. Provider business mailing address

1327 S WESTGATE AVE APT 303
LOS ANGELES CA
90025-1491
US

V. Phone/Fax

Practice location:
  • Phone: 562-286-1623
  • Fax:
Mailing address:
  • Phone: 562-286-1623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number56795
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: