Healthcare Provider Details

I. General information

NPI: 1477248532
Provider Name (Legal Business Name): CARLOS ANTONIO SOLIS PENA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14435 HAMLIN ST STE 101
VAN NUYS CA
91401-6205
US

IV. Provider business mailing address

19013 SCHOOLCRAFT ST
RESEDA CA
91335-3925
US

V. Phone/Fax

Practice location:
  • Phone: 818-988-7067
  • Fax:
Mailing address:
  • Phone: 818-943-1625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number108230
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: