=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831804392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOKATLI MATTAR DENTAL CORPORATION INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2023
-----------------------------------------------------
Last Update Date | 05/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16511 GOLDENWEST ST STE 108
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92647-4484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-395-6632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16511 GOLDENWEST ST STE 108
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92647-4484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-395-6632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DINA MATTAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-395-6632
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------