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General NPI Number Information
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NPI Number | 1720567548
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Entity Type | Organization
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Legal Business Name | BANTY DENTAL CORPORATION
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Dates
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Enumeration Date | 08/13/2018
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Last Update Date | 09/30/2018
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Provider Practice Location Address
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Address Line | 5971 S MAIN STREET
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City | LOS ANGELES
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State | CA
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Zip | 90003
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Country | US
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Telephone | 323-325-5641
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Fax |
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Provider Business Mailing Address
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Address Line | 387 W CHANNEL RD
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City | SANTA MONICA
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State | CA
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Zip | 90402-1107
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Country | US
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Telephone | 843-557-4335
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LAURA BANTY
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Credential | DMD
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Telephone | 843-557-4335
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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 | DDS100420
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License Number State | CA
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