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General NPI Number Information
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NPI Number | 1780072199
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Entity Type | Organization
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Legal Business Name | JASON MIRABILE DENTAL CORP
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Dates
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Enumeration Date | 01/07/2015
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Last Update Date | 01/12/2015
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Provider Practice Location Address
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Address Line | 1304 15TH ST 305
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City | SANTA MONICA
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State | CA
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Zip | 90404-1809
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Country | US
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Telephone | 310-319-9300
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Fax | 310-319-9320
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Provider Business Mailing Address
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Address Line | 1304 15TH ST 305
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City | SANTA MONICA
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State | CA
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Zip | 90404-1809
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Country | US
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Telephone | 310-319-9300
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Fax | 310-319-9320
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Authorized Official
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Title or Position | DENTIST
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Name | DR. JASON MIRABILE
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Credential | D.D.S.
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Telephone | 310-319-9300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 49147
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License Number State | CA
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