MEDICARE: FERNANDEZ-POBLETE 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	1223G0001X	General Practice Dentistry	47993	CA

General Provider Information

NPI Number	:	1598806614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FERNANDEZ-POBLETE DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	11631 VICTORY BLVD STE 102
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-3572
Country	:	US
Telephone Number	:	818-766-3660
Fax Number	:

Provider Business Practice Location Address
First Line	:	11631 VICTORY BLVD STE 102
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-3572
Country	:	US
Telephone Number	:	818-766-3660
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. EDITHA PASCUAL POBLETE
Credential	:
Telephone Number	:	818-766-3660

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	08/22/2020

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