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General NPI Number Information
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NPI Number | 1588800510
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Entity Type | Organization
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Legal Business Name | COURTNEY RAY MITTELMARK, D.M.D., M.S.D., A PROFESSIONAL CORP.
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Dates
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Enumeration Date | 12/22/2008
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Last Update Date | 01/25/2016
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Provider Practice Location Address
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Address Line | 8540 S SEPULVEDA BLVD #700
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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 | 310-216-0101
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Fax | 310-216-1279
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Provider Business Mailing Address
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Address Line | 8540 S SEPULVEDA BLVD #700
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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 | 310-216-0101
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Fax | 310-216-1279
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Authorized Official
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Title or Position | MANAGER
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Name | FABIOLA ORTEGA-FRASCH
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Credential |
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Telephone | 310-216-0101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 61908
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License Number State | CA
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