Provider Demographics
NPI:1033319983
Name:MICHAEL NY MA DENTAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL NY MA DENTAL CORPORATION
Other - Org Name:EAST WEST DENTAL OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:NY
Authorized Official - Last Name:MA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:213-617-9151
Mailing Address - Street 1:711 W COLLEGE ST
Mailing Address - Street 2:SUITE 570
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-1163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 W COLLEGE ST
Practice Address - Street 2:SUITE 570
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-1163
Practice Address - Country:US
Practice Address - Phone:213-617-9151
Practice Address - Fax:213-617-1428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA289541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty