Provider Demographics
NPI:1093103954
Name:DMITRY AMINOV DENTAL CORP
Entity Type:Organization
Organization Name:DMITRY AMINOV DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:AMINOV
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:805-520-1711
Mailing Address - Street 1:2780 TAPO CANYON RD
Mailing Address - Street 2:SUITE A-1B
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-6840
Mailing Address - Country:US
Mailing Address - Phone:805-520-1711
Mailing Address - Fax:805-520-1511
Practice Address - Street 1:2780 TAPO CANYON RD
Practice Address - Street 2:SUITE A-1B
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-6840
Practice Address - Country:US
Practice Address - Phone:805-520-1711
Practice Address - Fax:805-520-1511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA558891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1083800296OtherINDIVIDUAL NPI