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General NPI Number Information
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NPI Number | 1487056180
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Entity Type | Organization
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Legal Business Name | KIDS COMMUNITY CLINIC OF BURBANK
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Dates
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Enumeration Date | 09/24/2014
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Last Update Date | 09/24/2014
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Provider Practice Location Address
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Address Line | 400 W ELMWOOD AVE
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City | BURBANK
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State | CA
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Zip | 91506-3304
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Country | US
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Telephone | 818-841-8010
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Fax | 818-841-8006
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Provider Business Mailing Address
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Address Line | 400 W ELMWOOD AVE
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City | BURBANK
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State | CA
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Zip | 91506-3304
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Country | US
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Telephone | 818-841-8010
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Fax | 818-841-8006
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Authorized Official
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Title or Position | BOARD PRESIDENT, VOLUNTEER DENTIST
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Name | DR. RICHARD MARIAS
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Credential | DMD
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Telephone | 818-841-8010
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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 | 032653
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 27156
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 27544
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 126800000X
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Taxonomy Name | Dental Assistant
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License Number | 77534
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License Number State | CA
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Taxonomy #5
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DE33337
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License Number State | CA
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