Provider Demographics
NPI:1205000387
Name:EDWIN BARZALLO, DDS, INC.
Entity Type:Organization
Organization Name:EDWIN BARZALLO, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:O
Authorized Official - Last Name:BARZALLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-263-3300
Mailing Address - Street 1:741 S ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-3213
Mailing Address - Country:US
Mailing Address - Phone:323-263-3300
Mailing Address - Fax:323-263-3400
Practice Address - Street 1:741 S ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-3213
Practice Address - Country:US
Practice Address - Phone:323-263-3300
Practice Address - Fax:323-263-3400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49467122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9240601Medicaid