=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215070735
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOWARD D. BROSTOFF, D.D.S., INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 W LA VETA AVE SUITE 200
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92868-3901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-532-9700
-----------------------------------------------------
Fax | 714-532-9766
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 805 W LA VETA AVE SUITE 200
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92868-3901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-532-9700
-----------------------------------------------------
Fax | 714-532-9766
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES.
-----------------------------------------------------
Name | DR. HOWARD DAVID BROSTOFF
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 714-532-9700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 26150
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------