Healthcare Provider Details

I. General information

NPI: 1518846252
Provider Name (Legal Business Name): REYNA-BLANCO DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12405 VENTURA BLVD
STUDIO CITY CA
91604-2407
US

IV. Provider business mailing address

1147 N CLARK ST APT 105
WEST HOLLYWOOD CA
90069-2044
US

V. Phone/Fax

Practice location:
  • Phone: 818-518-9763
  • Fax:
Mailing address:
  • Phone: 509-699-8882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. OSCAR HUMBERTO REYNA-BLANCO
Title or Position: ORTHODONTIST / CEO
Credential: DDS, MMSC
Phone: 509-699-8882