=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891945317
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUBTSOV D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2008
-----------------------------------------------------
Last Update Date | 02/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12450 BURBANK BLVD
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91607-1637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-763-0777
-----------------------------------------------------
Fax | 818-763-0453
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12450 BURBANK BLVD 'L'
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91607-1637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-763-0777
-----------------------------------------------------
Fax | 818-763-0453
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VALERIY RUBTSOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-763-0777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 54304
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------