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NPI Code Detail

MEDICARE: MARK ANTHONY CARBAJAL DENTAL ASSISTANT

MEDICARE: MARK ANTHONY CARBAJAL DENTAL ASSISTANT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1126800000XDental Assistant449-735654CA

General Provider Information

NPI Number : 1215176052
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARK ANTHONY CARBAJAL DENTAL ASSISTANT
Provider Business Mailing Address
First Line : 2244 W 27TH ST
Second Line :
City : LOS ANGELES
State : CA
Zip : 90018-2529
Country : US
Telephone Number : 323-766-8154
Fax Number :
Provider Business Practice Location Address
First Line : 12121 WILSHIRE BLVD STE 1111
Second Line :
City : LOS ANGELES
State : CA
Zip : 90025-1188
Country : US
Telephone Number : 213-451-1313
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/18/2009
Last Update Date : 02/18/2009

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