Healthcare Provider Details

I. General information

NPI: 1215039151
Provider Name (Legal Business Name): DAVID DALE LYTAL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 15TH ST STE 1403
SANTA MONICA CA
90404-1106
US

IV. Provider business mailing address

1260 15TH ST STE 1403
SANTA MONICA CA
90404-1106
US

V. Phone/Fax

Practice location:
  • Phone: 310-394-1262
  • Fax: 310-394-7207
Mailing address:
  • Phone: 310-394-1262
  • Fax: 310-394-7207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number25585
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: