MEDICARE: LA SANTOS STARR DENTAL CORPORATION

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
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1447912761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA SANTOS STARR DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	6699 ALVARADO RD STE 2202
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5293
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1127 WILSHIRE BLVD STE 404
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-3905
Country	:	US
Telephone Number	:	323-600-5287
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	AMANDA DOS SANTOS
Credential	:
Telephone Number	:	619-204-8082

Provider Enumeration Date	:	10/13/2021
Last Update Date	:	10/13/2021

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