Healthcare Provider Details

I. General information

NPI: 1063950244
Provider Name (Legal Business Name): VAFA DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7865 SANTA MONICA BLVD
WEST HOLLYWOOD CA
90046-5344
US

IV. Provider business mailing address

7865 SANTA MONICA BLVD
WEST HOLLYWOOD CA
90046-5344
US

V. Phone/Fax

Practice location:
  • Phone: 323-654-2840
  • Fax:
Mailing address:
  • Phone: 323-654-2840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number52126
License Number StateCA

VIII. Authorized Official

Name: SANDY SCOTT
Title or Position: TX COORDINATOR
Credential:
Phone: 310-201-9001