Healthcare Provider Details

I. General information

NPI: 1588209712
Provider Name (Legal Business Name): RENATA CARVALHO DA FONSECA DDS., A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23101 SHERMAN PL STE 201
WEST HILLS CA
91307-2019
US

IV. Provider business mailing address

578 WASHINGTON BLVD UNIT 523
MARINA DEL REY CA
90292-5421
US

V. Phone/Fax

Practice location:
  • Phone: 818-716-8424
  • Fax:
Mailing address:
  • Phone: 310-463-3294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. RENATA CARVALHO DA FONSECA
Title or Position: PRESIDENT
Credential: DDS
Phone: 310-463-3294