Provider Demographics
NPI:1235426628
Name:MARILYN R. CALVO, D.D.S. A DENTAL CORP
Entity Type:Organization
Organization Name:MARILYN R. CALVO, D.D.S. A DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CALVO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-788-0905
Mailing Address - Street 1:16311 VENTURA BLVD
Mailing Address - Street 2:SUITE 527
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:818-788-0905
Mailing Address - Fax:818-788-1517
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:SUITE 527
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:818-788-0905
Practice Address - Fax:818-788-1517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28909122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93559-01Medicaid