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General NPI Number Information
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NPI Number | 1356745459
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Entity Type | Organization
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Legal Business Name | ECHARTE,FERNANDEZ PROFESSIONAL DENTAL CORPORATION
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Dates
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Enumeration Date | 10/17/2014
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Last Update Date | 10/17/2014
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Provider Practice Location Address
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Address Line | 525 S ALVARADO ST
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City | LOS ANGELES
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State | CA
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Zip | 90057-2903
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Country | US
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Telephone | 213-483-1234
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Fax |
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Provider Business Mailing Address
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Address Line | 525 S ALVARADO ST
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City | LOS ANGELES
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State | CA
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Zip | 90057-2903
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Country | US
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Telephone | 213-483-1234
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Fax |
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Authorized Official
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Title or Position | VICE-PRESIDENT
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Name | DR. OMAR JESUS FERNANDEZ
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Credential | DDS
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Telephone | 213-483-1234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 53449
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License Number State | CA
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