=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376875534
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LILI MIRTORABI, D.D.S., M.S., A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2010
-----------------------------------------------------
Last Update Date | 02/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11008 VALLEY MALL UNIT 203
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91731-2645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-279-9992
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7722 SEVILLE AVE
-----------------------------------------------------
City | HUNTINGTON PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90255-6316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LILI MIRTORABI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-978-4746
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 42574
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------