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General NPI Number Information
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NPI Number | 1285816793
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Entity Type | Individual
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Provider Name | MIRIAM VITA VAN ALLEN D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 11/27/2007
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Last Update Date | 11/27/2007
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Provider Practice Location Address
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Address Line | 5920 DEL AMO BLVD
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City | LAKEWOOD
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State | CA
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Zip | 90713-1949
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Country | US
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Telephone | 562-496-2000
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Fax | 562-497-2064
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Provider Business Mailing Address
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Address Line | 5920 DEL AMO BLVD
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City | LAKEWOOD
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State | CA
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Zip | 90713-1949
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Country | US
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Telephone | 310-500-9782
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Fax | 310-203-9915
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 53958
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License Number State | CA
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