Provider Demographics
NPI:1346333861
Name:POBLETE, EDITHA PASCUAL
Entity Type:Individual
Prefix:DR
First Name:EDITHA
Middle Name:PASCUAL
Last Name:POBLETE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11631 VICTORY BLVD. STE. 102
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606
Mailing Address - Country:US
Mailing Address - Phone:818-766-3660
Mailing Address - Fax:818-766-1867
Practice Address - Street 1:11631 VICTORY BLVD. STE. 102
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606
Practice Address - Country:US
Practice Address - Phone:818-766-3660
Practice Address - Fax:818-766-1867
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA479931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92361-01OtherDENTI-CAL