Provider Demographics
NPI:1083919781
Name:DENTAL SPECIALIST OF LOS ANGELES
Entity Type:Organization
Organization Name:DENTAL SPECIALIST OF LOS ANGELES
Other - Org Name:GENTLE CARE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERTRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIRI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-264-8834
Mailing Address - Street 1:3500 WHITTIER BLVD
Mailing Address - Street 2:101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-1746
Mailing Address - Country:US
Mailing Address - Phone:323-264-8834
Mailing Address - Fax:323-264-0885
Practice Address - Street 1:3500 WHITTIER BLVD
Practice Address - Street 2:101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-1746
Practice Address - Country:US
Practice Address - Phone:323-264-8834
Practice Address - Fax:323-264-0885
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENTLE CARE DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34586122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty