Healthcare Provider Details

I. General information

NPI: 1467842823
Provider Name (Legal Business Name): CHERRY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30057 VIA VICTORIA
RANCHO PALOS VERDES CA
90275-4435
US

IV. Provider business mailing address

6616 CHERRY AVE
LONG BEACH CA
90805-1715
US

V. Phone/Fax

Practice location:
  • Phone: 310-780-0106
  • Fax:
Mailing address:
  • Phone: 562-630-5616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: DR. AMANDA HANNA
Title or Position: ASSOCIATE DENTIST
Credential: DDS
Phone: 310-780-0106