Provider Demographics
NPI:1548800576
Name:CITY TERRACE DENTAL
Entity Type:Organization
Organization Name:CITY TERRACE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AQUILEO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-260-7173
Mailing Address - Street 1:3604 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-2326
Mailing Address - Country:US
Mailing Address - Phone:323-260-7173
Mailing Address - Fax:323-927-2363
Practice Address - Street 1:3604 E 1ST ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063-2326
Practice Address - Country:US
Practice Address - Phone:323-260-7173
Practice Address - Fax:323-927-2363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental