Healthcare Provider Details

I. General information

NPI: 1588800510
Provider Name (Legal Business Name): COURTNEY RAY MITTELMARK, D.M.D., M.S.D., A PROFESSIONAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2008
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8540 S SEPULVEDA BLVD #700
LOS ANGELES CA
90045-3807
US

IV. Provider business mailing address

8540 S SEPULVEDA BLVD #700
LOS ANGELES CA
90045-3807
US

V. Phone/Fax

Practice location:
  • Phone: 310-216-0101
  • Fax: 310-216-1279
Mailing address:
  • Phone: 310-216-0101
  • Fax: 310-216-1279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number61908
License Number StateCA

VIII. Authorized Official

Name: FABIOLA ORTEGA-FRASCH
Title or Position: MANAGER
Credential:
Phone: 310-216-0101