Healthcare Provider Details

I. General information

NPI: 1548763808
Provider Name (Legal Business Name): CLAUDIA VIDES SAMARITANA DENTAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S ALVARADO ST STE 208
LOS ANGELES CA
90057-2904
US

IV. Provider business mailing address

510 S ALVARADO ST STE 208
LOS ANGELES CA
90057-2904
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-3600
  • Fax:
Mailing address:
  • Phone: 213-483-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number56246
License Number StateCA

VIII. Authorized Official

Name: MS. HEATHER C MARSAC
Title or Position: REGIONAL DIRECTOR
Credential: RDA
Phone: 562-310-6856