Healthcare Provider Details

I. General information

NPI: 1720317456
Provider Name (Legal Business Name): RODERIK STEVEN ALAY DA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 SEPULVEDA BLVD
TORRANCE CA
90505-2408
US

IV. Provider business mailing address

3820 SEPULVEDA BLVD
TORRANCE CA
90505-2408
US

V. Phone/Fax

Practice location:
  • Phone: 310-792-5200
  • Fax: 310-792-5201
Mailing address:
  • Phone: 310-792-5200
  • Fax: 310-792-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number4481020
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: