Healthcare Provider Details

I. General information

NPI: 1225145568
Provider Name (Legal Business Name): DONALD A SALEM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11980 SAN VICENTE BLVD SUITE 814
LOS ANGELES CA
90049
US

IV. Provider business mailing address

11980 SAN VICENTE BLVD SUITE 814
LOS ANGELES CA
90049-5012
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-4986
  • Fax:
Mailing address:
  • Phone: 310-820-4986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD20454
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD20454
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: