Healthcare Provider Details

I. General information

NPI: 1811699184
Provider Name (Legal Business Name): JUSTIN PRATT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 10/11/2026
Certification Date: 10/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 TIVERTON AVE
LOS ANGELES CA
90095-8361
US

IV. Provider business mailing address

714 TIVERTON AVE
LOS ANGELES CA
90095-8361
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-0834
  • Fax:
Mailing address:
  • Phone: 310-825-0834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDDS113060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: