Healthcare Provider Details

I. General information

NPI: 1932541059
Provider Name (Legal Business Name): DR. KOLODNER DENTAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12215 VENTURA BLVD SUITE 115
STUDIO CITY CA
91604-2533
US

IV. Provider business mailing address

12215 VENTURA BLVD SUITE 115
STUDIO CITY CA
91604-2533
US

V. Phone/Fax

Practice location:
  • Phone: 818-761-9526
  • Fax: 818-755-6757
Mailing address:
  • Phone: 818-761-9526
  • Fax: 818-755-6757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. TATYANA KOLODNER
Title or Position: SECRETARY
Credential: DDS
Phone: 818-761-9526