=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134659857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRIEDMAN PROFESSIONAL DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10318 ROSECRANS AVE
-----------------------------------------------------
City | BELLFLOWER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90706-2702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-925-3765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10318 ROSECRANS AVE
-----------------------------------------------------
City | BELLFLOWER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90706-2702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-925-3765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST
-----------------------------------------------------
Name | MARVIN AARON FRIEDMAN
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 562-925-3765
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DDS26061
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------