Healthcare Provider Details

I. General information

NPI: 1194983825
Provider Name (Legal Business Name): DINA KIKUE BRENT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 E 4TH ST
LOS ANGELES CA
90033-4201
US

IV. Provider business mailing address

311 WINSTON ST
LOS ANGELES CA
90013-1519
US

V. Phone/Fax

Practice location:
  • Phone: 213-893-1960
  • Fax: 213-229-9061
Mailing address:
  • Phone: 213-893-1960
  • Fax: 213-893-1967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG46412
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: