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General NPI Number Information
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NPI Number | 1831458637
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Entity Type | Organization
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Legal Business Name | GREENVALLEY ORAL CARE
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Dates
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Enumeration Date | 05/14/2012
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Last Update Date | 05/14/2012
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Provider Practice Location Address
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Address Line | 3516 MARTIN LUTHER KING BLVD. SUITE 7
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City | LYNWOOD
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State | CA
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Zip | 90262
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Country | US
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Telephone | 310-639-7224
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Fax | 310-639-3939
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Provider Business Mailing Address
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Address Line | 3516 MARTIN LUTHER KING BLVD. SUITE 7
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City | LYNWOOD
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State | CA
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Zip | 90262
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Country | US
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Telephone | 310-639-7224
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Fax | 310-639-3939
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Authorized Official
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Title or Position | DENTIST
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Name | RAFAEL A ANTILLON
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Credential |
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Telephone | 310-639-7224
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 39747
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License Number State | CA
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