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General NPI Number Information
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NPI Number | 1265913081
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Entity Type | Organization
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Legal Business Name | KONVISER DENTAL PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 08/29/2018
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Last Update Date | 08/29/2018
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Provider Practice Location Address
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Address Line | 4644 LINCOLN BLVD STE 404
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City | MARINA DEL REY
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State | CA
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Zip | 90292-6380
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Country | US
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Telephone | 310-578-2500
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Fax |
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Provider Business Mailing Address
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Address Line | 4644 LINCOLN BLVD STE 404
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City | MARINA DEL REY
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State | CA
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Zip | 90292-6380
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Country | US
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Telephone | 310-578-2500
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | VADIM KONVISER
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Credential | DDS
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Telephone | 310-578-2500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 51095
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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 | 51095
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License Number State | CA
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