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General NPI Number Information
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NPI Number | 1619850088
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Entity Type | Organization
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Legal Business Name | DMITRIY IVANOV, DDS DENTAL CORP
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Dates
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Enumeration Date | 07/31/2025
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Last Update Date | 07/31/2025
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Provider Practice Location Address
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Address Line | 390 N PACIFIC COAST HWY STE 1070
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City | EL SEGUNDO
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State | CA
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Zip | 90245-4483
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Country | US
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Telephone | 310-708-3938
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Fax |
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Provider Business Mailing Address
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Address Line | 2406 MATHEWS AVE UNIT A
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City | REDONDO BEACH
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State | CA
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Zip | 90278-5503
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Country | US
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Telephone | 310-926-8985
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. DMITRIY V IVANOV
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Credential | DDS
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Telephone | 310-926-8985
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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