1598350100 NPI number — MINYE CENTER FOR RECONSTRUCTIVE DENTISTRY & ORAL SURGERY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598350100 NPI number — MINYE CENTER FOR RECONSTRUCTIVE DENTISTRY & ORAL SURGERY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINYE CENTER FOR RECONSTRUCTIVE DENTISTRY & ORAL SURGERY, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598350100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 HIGHLAND PARK VILLAGE
Provider Second Line Business Mailing Address:
BLDG 100 STE171
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18981 VENTURA BLVD
Provider Second Line Business Practice Location Address:
2ND FLOOR, SUITE 200
Provider Business Practice Location Address City Name:
TARZANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-312-5819
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MINYE
Authorized Official First Name:
HELENA
Authorized Official Middle Name:
MALOUS
Authorized Official Title or Position:
CHIEF DENTAL OFFICER
Authorized Official Telephone Number:
818-312-5819

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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