Healthcare Provider Details

I. General information

NPI: 1306802590
Provider Name (Legal Business Name): RICHARD WURTZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ALOHA DR
PACIFIC PALISADES CA
90272-4639
US

IV. Provider business mailing address

1 ALOHA DR
PACIFIC PALISADES CA
90272-4639
US

V. Phone/Fax

Practice location:
  • Phone: 310-880-8011
  • Fax:
Mailing address:
  • Phone: 310-880-8011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number34446
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: