Healthcare Provider Details

I. General information

NPI: 1295556322
Provider Name (Legal Business Name): ANNA KOLENTSOVA DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12043 MAGNOLIA BLVD
VALLEY VILLAGE CA
91607-2740
US

IV. Provider business mailing address

12043 MAGNOLIA BLVD
VALLEY VILLAGE CA
91607-2740
US

V. Phone/Fax

Practice location:
  • Phone: 818-761-8274
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANNA KOLENTSOVA
Title or Position: PRESIDENT
Credential: DDS
Phone: 310-430-2410