Healthcare Provider Details

I. General information

NPI: 1548545866
Provider Name (Legal Business Name): CARMONA DENTAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2011
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4096 TWEEDY BLVD
SOUTH GATE CA
90280-6147
US

IV. Provider business mailing address

4096 TWEEDY BLVD
SOUTH GATE CA
90280-6147
US

V. Phone/Fax

Practice location:
  • Phone: 323-569-3333
  • Fax: 323-569-3334
Mailing address:
  • Phone: 323-569-3333
  • Fax: 323-569-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60024
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: ENRIQUETA CARMONA
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 323-569-3333