Healthcare Provider Details

I. General information

NPI: 1760678908
Provider Name (Legal Business Name): DONNA JANE ETESON D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 OCEAN PARK BLVD SUITE 304
SANTA MONICA CA
90405-5215
US

IV. Provider business mailing address

2601 OCEAN PARK BLVD SUITE 304
SANTA MONICA CA
90405-5215
US

V. Phone/Fax

Practice location:
  • Phone: 310-581-5757
  • Fax: 310-581-5759
Mailing address:
  • Phone: 310-581-5757
  • Fax: 310-581-5759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number27124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: