Provider Demographics
NPI:1275038382
Name:VERSHININ DENTAL CORPORATION
Entity Type:Organization
Organization Name:VERSHININ DENTAL CORPORATION
Other - Org Name:BEVERLY HILLS BIODENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GOAR
Authorized Official - Middle Name:
Authorized Official - Last Name:VERSHININA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-990-5787
Mailing Address - Street 1:416 N BEDFORD DR STE 103
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4308
Mailing Address - Country:US
Mailing Address - Phone:310-990-5787
Mailing Address - Fax:424-302-0099
Practice Address - Street 1:416 N BEDFORD DR STE 103
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4308
Practice Address - Country:US
Practice Address - Phone:310-990-5787
Practice Address - Fax:424-302-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-29
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS100895122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF1547663Medicaid
CAE3026942Medicaid