Healthcare Provider Details

I. General information

NPI: 1578177804
Provider Name (Legal Business Name): ROBERT VALLE JR. RDA84376
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12121 WILSHIRE BLVD
LOS ANGELES CA
90025-1123
US

IV. Provider business mailing address

12121 WILSHIRE BLVD STE 1111
LOS ANGELES CA
90025-1188
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-9933
  • Fax:
Mailing address:
  • Phone: 310-820-9933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number84376
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: