Provider Demographics
NPI:1235371600
Name:ANATOLY VAISMAN D.D.S., INC
Entity Type:Organization
Organization Name:ANATOLY VAISMAN D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGE
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-365-7191
Mailing Address - Street 1:11273 LAUREL CANYON BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-4358
Mailing Address - Country:US
Mailing Address - Phone:818-365-7191
Mailing Address - Fax:818-361-7641
Practice Address - Street 1:11273 LAUREL CANYON BLVD STE 3
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4358
Practice Address - Country:US
Practice Address - Phone:818-365-7191
Practice Address - Fax:818-361-7641
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANATOLY VAISMAN D.D., INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA432591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93630-01Medicaid