Provider Demographics
NPI:1104000934
Name:MOBILE TEETH CLEANING
Entity Type:Organization
Organization Name:MOBILE TEETH CLEANING
Other - Org Name:AARON BENITEZ, RDHAP
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:BENITEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RDHAP
Authorized Official - Phone:323-333-9938
Mailing Address - Street 1:3205 LOS FELIZ BL
Mailing Address - Street 2:13309
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-1554
Mailing Address - Country:US
Mailing Address - Phone:323-333-9938
Mailing Address - Fax:323-446-7313
Practice Address - Street 1:3205 LOS FELIZ BL
Practice Address - Street 2:13309
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-1554
Practice Address - Country:US
Practice Address - Phone:323-333-9938
Practice Address - Fax:323-446-7313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP173124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZ8978301Medicaid