Healthcare Provider Details

I. General information

NPI: 1043458490
Provider Name (Legal Business Name): MAGICLAND DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2009
Last Update Date: 01/22/2009
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:
Mailing address:
  • Phone: 310-792-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number4490733
License Number StateCA

VIII. Authorized Official

Name: MARIA F HUANOSTO
Title or Position: ASSISTANCE
Credential: DA
Phone: 310-329-8241