Provider Demographics
NPI:1255496782
Name:UNTALAN, CHARISE RUBY (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARISE
Middle Name:RUBY
Last Name:UNTALAN
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 1:5009 ALTA CANYADA RD
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-1716
Mailing Address - Country:US
Mailing Address - Phone:818-952-2630
Mailing Address - Fax:213-385-2144
Practice Address - Street 1:730 S WESTERN AVE STE 202
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-5901
Practice Address - Country:US
Practice Address - Phone:213-385-3828
Practice Address - Fax:213-385-2144
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA499841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9241201Medicaid