=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972679124
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK TREYSTMAN DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 10/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6333 WILSHIRE BLVD 207
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-5702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-653-5484
-----------------------------------------------------
Fax | 323-653-5485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6333 WILSHIRE BLVD 207
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-5702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-653-5484
-----------------------------------------------------
Fax | 323-653-5485
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MARK TREYSTMAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 323-653-5484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 45416
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------