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General NPI Number Information
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NPI Number | 1871772368
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Entity Type | Organization
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Legal Business Name | DENTALVILLE
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Dates
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Enumeration Date | 10/31/2007
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Last Update Date | 10/31/2007
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Provider Practice Location Address
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Address Line | 1180 S BEVERLY DR STE 401
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City | LOS ANGELES
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State | CA
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Zip | 90035-1156
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Country | US
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Telephone | 310-804-1972
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Fax |
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Provider Business Mailing Address
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Address Line | 945 S RAINBOW BLVD
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City | LAS VEGAS
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State | NV
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Zip | 89145-6230
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Country | US
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Telephone | 702-258-8216
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Fax | 702-870-0974
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Authorized Official
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Title or Position | REGIONAL MANAGER
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Name | MARINA KOZYR
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Credential |
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Telephone | 310-804-1972
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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 | 3580
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License Number State | NV
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