Provider Demographics
NPI:1508528142
Name:MONA DERENTZ D.D.S., INC
Entity Type:Organization
Organization Name:MONA DERENTZ D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:DERENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:805-630-4541
Mailing Address - Street 1:19100 VENTURA BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3234
Mailing Address - Country:US
Mailing Address - Phone:818-925-2599
Mailing Address - Fax:
Practice Address - Street 1:19100 VENTURA BLVD STE 3
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3234
Practice Address - Country:US
Practice Address - Phone:818-925-2599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty