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General NPI Number Information
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NPI Number | 1043575798
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Entity Type | Organization
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Legal Business Name | OFELIA K. COSTALES, D.D.S., INC.
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Dates
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Enumeration Date | 07/09/2012
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Last Update Date | 07/09/2012
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Provider Practice Location Address
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Address Line | 23517 SOUTH MAIN ST STE 102
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City | CARSON
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State | CA
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Zip | 90745
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Country | US
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Telephone | 310-518-6802
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Fax |
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Provider Business Mailing Address
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Address Line | 23517 SOUTH MAIN ST STE 102
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City | CARSON
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State | CA
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Zip | 90745
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Country | US
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Telephone | 310-518-6802
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. OFELIA KARAAN COSTALES
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Credential | D.D.S.
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Telephone | 310-518-6802
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 48250
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License Number State | CA
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