Healthcare Provider Details

I. General information

NPI: 1003293093
Provider Name (Legal Business Name): PETER DENTONE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 12/17/2021
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 STEIN PLAZA #1-340
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA161470
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberA161470
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: