Healthcare Provider Details

I. General information

NPI: 1770402893
Provider Name (Legal Business Name): SURFSIDE COLLECTIVE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23601 CRENSHAW BLVD
TORRANCE CA
90505-5204
US

IV. Provider business mailing address

1601 N SEPULVEDA BLVD # 354
MANHATTAN BEACH CA
90266-5111
US

V. Phone/Fax

Practice location:
  • Phone: 424-538-4752
  • Fax:
Mailing address:
  • Phone: 503-886-9635
  • 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: JOHN MILLER
Title or Position: PRESIDENT
Credential: DDS
Phone: 503-886-9635