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General NPI Number Information
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NPI Number | 1508245192
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Entity Type | Organization
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Legal Business Name | THEODORE BURNETT, DDS, INC
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Dates
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Enumeration Date | 05/28/2015
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Last Update Date | 05/28/2015
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Provider Practice Location Address
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Address Line | 8540 S SEPULVEDA BLVD SUITE 918
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City | LOS ANGELES
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State | CA
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Zip | 90045-3807
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Country | US
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Telephone | 310-670-0379
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Fax | 310-670-0922
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Provider Business Mailing Address
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Address Line | 8540 S SEPULVEDA BLVD SUITE 918
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City | LOS ANGELES
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State | CA
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Zip | 90045-3807
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Country | US
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Telephone | 310-670-0379
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Fax | 310-670-0922
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | THEODORE BURNETT
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Credential | DDS
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Telephone | 310-670-0379
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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 | 36342
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License Number State | CA
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