Healthcare Provider Details

I. General information

NPI: 1619090214
Provider Name (Legal Business Name): NINA MANDELMAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 ERRINGER RD SUITE 20
SIMI VALLEY CA
93065-6507
US

IV. Provider business mailing address

1755 ERRINGER RD SUITE 20
SIMI VALLEY CA
93065-6507
US

V. Phone/Fax

Practice location:
  • Phone: 805-522-2164
  • Fax: 805-522-9849
Mailing address:
  • Phone: 805-522-2164
  • Fax: 805-522-9849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number44936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: