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General NPI Number Information
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NPI Number | 1043634124
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Entity Type | Organization
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Legal Business Name | ALAMITOS ORAL SURGERY
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Dates
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Enumeration Date | 02/11/2014
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Last Update Date | 02/18/2014
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Provider Practice Location Address
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Address Line | 4582 KATELLA AVENUE
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City | LOS ALAMITOS
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State | CA
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Zip | 90720
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Country | US
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Telephone | 310-279-0993
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Fax |
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Provider Business Mailing Address
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Address Line | 4582 KATELLA AVENUE
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City | LOS ALAMITOS
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State | CA
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Zip | 90720
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ORAL SURGEON/CO-OWNER
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Name | SOLOMON POYOUROW
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Credential | D.D.S., M.D., M.P.H.
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Telephone | 310-279-0993
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 55453
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 58092
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 56129
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License Number State | CA
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