Provider Demographics
NPI:1376875534
Name:LILI MIRTORABI, D.D.S., M.S., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LILI MIRTORABI, D.D.S., M.S., A PROFESSIONAL CORPORATION
Other - Org Name:LILI MIRTORABI ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LILI
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRTORABI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-978-4746
Mailing Address - Street 1:7722 SEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-6316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11008 VALLEY MALL UNIT 203
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-2645
Practice Address - Country:US
Practice Address - Phone:626-279-9992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA425741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA42574OtherDENTAL LICENSE