Healthcare Provider Details

I. General information

NPI: 1629648860
Provider Name (Legal Business Name): HUTALLA ESTELLA DENTAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 W RANCHO VISTA BLVD STE 102
PALMDALE CA
93551-3010
US

IV. Provider business mailing address

16733 LA VEDA AVE
CANYON COUNTRY CA
91387-1723
US

V. Phone/Fax

Practice location:
  • Phone: 661-402-1699
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. BRAN'D HUTALLA ESTELLA
Title or Position: DENTIST
Credential: DMD
Phone: 323-369-8228