1659811065 NPI number — WORMSER SMILES DENTAL OFFICE INC

Table of content: (NPI 1659811065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659811065 NPI number — WORMSER SMILES DENTAL OFFICE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WORMSER SMILES DENTAL OFFICE INC
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:
1659811065
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 VIA DE LA PAZ
Provider Second Line Business Mailing Address:
108
Provider Business Mailing Address City Name:
PACIFIC PALISADES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90272-3515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-454-3732
Provider Business Mailing Address Fax Number:
310-459-2245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 VIA DE LA PAZ
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
PACIFIC PALISADES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90272-3515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-454-3732
Provider Business Practice Location Address Fax Number:
310-459-2245
Provider Enumeration Date:
03/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WORMSER
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
PHILIP
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-454-3732

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  28832 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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