Healthcare Provider Details

I. General information

NPI: 1578631800
Provider Name (Legal Business Name): ATEF R. REZKALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11481 ROSECRANS AVE
NORWALK CA
90650-3830
US

IV. Provider business mailing address

308 ORANGE AVE
LONG BEACH CA
90802-3536
US

V. Phone/Fax

Practice location:
  • Phone: 562-863-3457
  • Fax:
Mailing address:
  • Phone: 562-436-4214
  • Fax: 562-435-3067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number48004
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: