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General NPI Number Information
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NPI Number | 1629784046
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Entity Type | Organization
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Legal Business Name | FUNDAMINSKY ORAL FACIAL DDS INC
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Dates
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Enumeration Date | 01/30/2023
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Last Update Date | 01/30/2023
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Provider Practice Location Address
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Address Line | 9615 BRIGHTON WAY STE 216
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City | BEVERLY HILLS
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State | CA
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Zip | 90210-5118
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Country | US
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Telephone | 310-278-0814
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Fax |
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Provider Business Mailing Address
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Address Line | 9615 BRIGHTON WAY STE 216
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City | BEVERLY HILLS
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State | CA
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Zip | 90210-5118
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | GENNADY M FUNDAMINSKY
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Credential | MD, DDS
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Telephone | 310-801-1296
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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 |
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License Number State |
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