Healthcare Provider Details

I. General information

NPI: 1104000934
Provider Name (Legal Business Name): MOBILE TEETH CLEANING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 LOS FELIZ BL 13309
LOS ANGELES CA
90039-1554
US

IV. Provider business mailing address

3205 LOS FELIZ BL 13309
LOS ANGELES CA
90039-1554
US

V. Phone/Fax

Practice location:
  • Phone: 323-333-9938
  • Fax: 323-446-7313
Mailing address:
  • Phone: 323-333-9938
  • Fax: 323-446-7313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberHAP173
License Number StateCA

VIII. Authorized Official

Name: MR. AARON BENJAMIN BENITEZ
Title or Position: OWNER
Credential: RDHAP
Phone: 323-333-9938