Healthcare Provider Details

I. General information

NPI: 1205808243
Provider Name (Legal Business Name): RAMSTRUM DENTAL PRACTICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 W MANCHESTER AVE
LOS ANGELES CA
90044-5718
US

IV. Provider business mailing address

643 W MANCHESTER AVE
LOS ANGELES CA
90044-5718
US

V. Phone/Fax

Practice location:
  • Phone: 323-753-1411
  • Fax: 323-753-3109
Mailing address:
  • Phone: 323-753-1411
  • Fax: 323-753-3109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2642169-3
License Number StateCA

VIII. Authorized Official

Name: DR. DAGMAR JOHANNA RAMSTRUM
Title or Position: OWNER
Credential: D.D.S.
Phone: 323-753-1411