Healthcare Provider Details

I. General information

NPI: 1114489820
Provider Name (Legal Business Name): DDS DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 S ROBERTSON BLVD
LOS ANGELES CA
90048-3208
US

IV. Provider business mailing address

140 S ROBERTSON BLVD
LOS ANGELES CA
90048-3208
US

V. Phone/Fax

Practice location:
  • Phone: 213-314-6612
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SADI KERMANI
Title or Position: DELEGATED REPRSENTATIVE
Credential:
Phone: 213-314-6612