Healthcare Provider Details

I. General information

NPI: 1831670637
Provider Name (Legal Business Name): KONVISER DENTAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4644 LINCOLN BLVD STE 404
MARINA DEL REY CA
90292-6380
US

IV. Provider business mailing address

4644 LINCOLN BLVD STE 404
MARINA DEL REY CA
90292-6380
US

V. Phone/Fax

Practice location:
  • Phone: 310-578-2500
  • Fax:
Mailing address:
  • Phone: 310-578-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number51095
License Number StateCA

VIII. Authorized Official

Name: VADIM KONVISER
Title or Position: CEO
Credential: DDS
Phone: 310-578-2500