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General NPI Number Information
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NPI Number | 1174702187
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Entity Type | Organization
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Legal Business Name | MAXILLOFACIAL SURGICAL ARTS
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Dates
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Enumeration Date | 10/25/2007
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Last Update Date | 10/25/2007
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Provider Practice Location Address
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Address Line | 9066 TAMPA AVE
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City | NORTHRIDGE
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State | CA
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Zip | 91324-3523
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Country | US
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Telephone | 818-993-5700
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Fax |
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Provider Business Mailing Address
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Address Line | 9066 TAMPA AVE
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City | NORTHRIDGE
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State | CA
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Zip | 91324-3523
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Country | US
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Telephone | 818-993-5700
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | DR. ROBERT RELLE
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Credential | D.D.S.
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Telephone | 818-993-5700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 034203
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License Number State | CA
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