=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003721689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOO SPARK DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2026
-----------------------------------------------------
Last Update Date | 08/17/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1194 S LORENA ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90023-2928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-526-8189
-----------------------------------------------------
Fax | 323-526-8314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1194 S LORENA ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90023-2928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-526-8189
-----------------------------------------------------
Fax | 323-526-8314
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARCOS JAVIER TORRES
-----------------------------------------------------
Credential | CEO
-----------------------------------------------------
Telephone | 347-913-2382
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------