MEDICARE: SAMUEL ROXAS AND LEONCIA ROXAS DENTAL CORP

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	41532	CA

General Provider Information

NPI Number	:	1609089507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMUEL ROXAS AND LEONCIA ROXAS DENTAL CORP

Provider Business Mailing Address
First Line	:	3130 W. 6TH ST. SUITE1
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-1702
Country	:	US
Telephone Number	:	213-382-5650
Fax Number	:	213-382-1443

Provider Business Practice Location Address
First Line	:	3130 W. 6TH ST.
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-1702
Country	:	US
Telephone Number	:	213-382-5650
Fax Number	:	213-382-1443

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SAMUEL C ROXAS
Credential	:	DMD
Telephone Number	:	213-382-5650

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	08/22/2020

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