MEDICARE: LA DELL 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1942082698
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA DELL DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	1127 WILSHIRE BLVD STE 404
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-3905
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 WOLFF
Credential	:
Telephone Number	:	213-423-1127

Provider Enumeration Date	:	10/17/2023
Last Update Date	:	10/17/2023

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Directions to “LA DELL DENTAL CORPORATION ” Practice Location

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