Healthcare Provider Details

I. General information

NPI: 1790186757
Provider Name (Legal Business Name): DAVID W. DORFMAN, MD, DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

881 ALMA REAL DR SUITE 204
PACIFIC PALISADES CA
90272-3731
US

IV. Provider business mailing address

881 ALMA REAL DR SUITE 204
PACIFIC PALISADES CA
90272-3731
US

V. Phone/Fax

Practice location:
  • Phone: 310-857-2088
  • Fax:
Mailing address:
  • Phone: 310-857-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberA106340
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA106340
License Number StateCA

VIII. Authorized Official

Name: DAVID WADE DORFMAN
Title or Position: CEO
Credential: M.D., D.D.S.
Phone: 949-387-6653