Healthcare Provider Details

I. General information

NPI: 1902204019
Provider Name (Legal Business Name): GENNADY ORLOVETSKY, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 TAPO CANYON RD STE. A-1B
SIMI VALLEY CA
93063-6840
US

IV. Provider business mailing address

2780 TAPO CANYON RD STE. A-1B
SIMI VALLEY CA
93063-6840
US

V. Phone/Fax

Practice location:
  • Phone: 805-520-1711
  • Fax: 805-520-1511
Mailing address:
  • Phone: 805-520-1711
  • Fax: 805-520-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LYUDMILA PREYS
Title or Position: OFFICE MANAGER
Credential:
Phone: 805-520-1711