Provider Demographics
NPI:1114297447
Name:FUNDORA, IDENIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:IDENIS
Middle Name:
Last Name:FUNDORA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 W SUNSET BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90069-3704
Mailing Address - Country:US
Mailing Address - Phone:310-274-7124
Mailing Address - Fax:
Practice Address - Street 1:9201 W SUNSET BLVD STE 315
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90069-3704
Practice Address - Country:US
Practice Address - Phone:310-274-7124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA476211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice